Remote Utilization Management RN — Pre-Authorization

Humana; Town of Florida (NY); Remote; USD 71,000 - 98,000; Full time

Benefits offered by this job

Bonus incentive plan

Job summary

Humana seeks a Pre-Authorization Nurse to review prior authorization requests, perform medical necessity assessments, and educate providers on utilization processes. The role requires an active RN license (VA or compact with eNLC), 2+ years in acute care or rehab, and strong MS Office skills.

Remote work is allowed with occasional travel as needed and a 40-hour workweek. Candidates should have experience in utilization/case management, discharge planning, or home health, and be able to work

Qualifications

• Active RN license in VA or compact state (eNLC) with no disciplinary action.
• Minimum 2 years nursing experience in acute care, skilled, or rehab setting.
• Experience in utilization management, case management, discharge planning and/or home health/rehab.
• Proficient in Microsoft Word, Excel, PowerPoint; able to navigate multiple systems remotely.
• Ability to work independently under general instructions and with a team.

Responsibilities

• Review prior authorization requests and approve services or forward to stakeholder as needed.
• Complete medical necessity and level of care reviews using clinical judgment.
• Educate providers on utilization and medical management processes.
• Enter and maintain clinical information in medical management systems; understand dept. strategy and linkages.
• Make decisions with minimal direction, following established guidelines.

Skills

RN license

Clinical nursing experience

Utilization management

MS Office proficiency

Independent worker + team player

Tools

MCG guidelines

InterQual guidelines

Job description

Humana seeks a Pre-Authorization Nurse to review prior authorization requests, perform medical necessity assessments, and educate providers on utilization processes. The role requires an active RN license (VA or compact with eNLC), 2+ years in acute care or rehab, and strong MS Office skills.

Remote work is allowed with occasional travel as needed and a 40-hour workweek. Candidates should have experience in utilization/case management, discharge planning, or home health, and be able to work