Pre-Authorization Registered Nurse

Become a part of our caring community and help us put health first
 The Pre-Authorization Nurse 2 reviews prior authorization requests for appropriate care and setting, following guidelines and policies, and approves services or forward requests to the appropriate stakeholder. The Pre-Authorization Nurse 2 work assignments are often straightforward and of moderate complexity.

The Pre-Authorization Nurse 2 completes medical necessity and level of care reviews for requested services using clinical judgment, and refers to internal stakeholders for review depending on case findings. Educates providers on utilization and medical management processes. Enters and maintains pertinent clinical information in various medical management systems. Understands own work area professional concepts/standards, regulations, strategies and operating standards. Makes decisions regarding own work approach/priorities, and follows direction. Work is managed and often guided by precedent and/or documented procedures/regulations/professional standards with some interpretation.

Use your skills to make an impact
 

Required Qualifications

• Active enhance license compact, (eNLC), Registered Nurse, RN, without restrictions or disciplinary actions,

• A minimum of three, (3) years varied nursing experience,

• Intermediate to Advanced knowledge of MS Office including Word, Excel, PowerPoint, and Teams in a Windows based environment and an ability to quickly learn new systems and ability to troubleshoot and resolve basic technical difficulties in a remote environment,

• Ability to work independently under general instructions and with a team.

Preferred Qualifications

• Health Plan experience working with large carriers,

• Previous Medicare/Medicaid experience a plus,

• Previous experience in pre-authorization, utilization management, case management, discharge planning and/or home health or rehab,

• Experience working with MCG or Interqual guidelines,

• Working knowledge using the following systems/platforms CGX, MHK, Maccess, CAS.

Additional Requirements/Adherence

Workstyle: Remote work at home

Preferred Location: United States

Training Schedule: Must be able to attend training schedule. Monday - Friday; 8:00am - 5:00pm Eastern

Schedule:

• Must be able to work a 40-hour work week, Monday through Friday, 8:00 AM to 5:00 PM Eastern Time and rotating weekends. and holidays. Leader will discuss during interview.

• Over-time may be requested to meet business needs.

Travel: None

Work at Home Guidance

• Must have accessibility to hardwired high speed internet with minimum speeds of 25Mx10M for a home office (Wireless and Satellite are prohibited).

• Associates who live and work from Home in the state of California, Illinois, Montana, or South Dakota will be provided a bi-weekly payment for their internet expense.

• Humana will provide Home or Hybrid Home/Office associates with telephone equipment appropriate to meet the business …