Pre-Authorization Nurse 2 at Humana

Milwaukee, Wisconsin, United States

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Not SpecifiedCompensation

Mid-level (3 to 4 years)Experience Level

Full TimeJob Type

UnknownVisa

HealthcareIndustries

Requirements

Associates degree in Nursing
Active and in good standing RN license for the State of WI
2 or more years of nursing experience
Proficient with MS Office products including Word, Excel and Outlook
Must be able to work the hours of 8:30-5 pm in Central Standard Time

Responsibilities

Receive requests for inpatient rehab, long-term acute care hospital, and skilled nursing facilities
Conduct reviews for medical necessity and appropriate level of care, utilizing clinical judgment and established guidelines
Adhere to established procedures and guidelines throughout all work activities
Refer cases to reviewing medical directors and leadership for further review based on findings
Collaborate, communicate and partner with Care Management teams on discharge planning to ensure a smooth process for members
Collaborate with the Enrollment department on any eligibility discrepancies between the provider and Humana/iCare team
Active contributor of the Provider Quality Committee, reviewing requests to ensure members have a safe facility to discharge to
Provide education to providers regarding utilization management and medical management processes
Enter and maintain accurate documentation in medical management systems
Demonstrate understanding of department, segment, and organizational strategy and operating objectives, including their interconnections
Make independent decisions regarding work methods with minimal supervision

Skills

Nursing

Pre-Authorization

Utilization Management

Medical Necessity Review

Clinical Guidelines

Discharge Planning

Care Management

Medical Documentation

Humana

Health insurance provider for seniors and military

About Humana

Humana provides health and well-being services, focusing on Medicare Advantage plans for seniors, military personnel, and communities. Their plans include HMO, PPO, and PFFS options, designed to improve health outcomes through comprehensive and flexible coverage. Humana's revenue comes from government contracts and member premiums, and they aim to maintain high renewal rates by offering quality service and competitive benefits. The company stands out by fostering a culture of inclusivity and belonging among its employees, while also ensuring accessibility for all members, including offering free language interpreter services. Humana's goal is to deliver value to its members through an extensive provider network and innovative health solutions.

Louisville, KentuckyHeadquarters

1961Year Founded

IPOCompany Stage

Social Impact, HealthcareIndustries

10,001+Employees

Risks

Potential over-reliance on AI could disrupt operations if systems fail or are compromised.

Rising medical costs and tightening Medicare reimbursements may strain financial performance.

Leadership change with new CEO Jim Rechtin could lead to strategic disruptions.

Differentiation

Humana is a leader in Medicare Advantage plans, focusing on seniors and military personnel.

The company emphasizes inclusivity, offering free language interpreter services for accessibility.

Humana leverages AI and cloud technologies through a partnership with Google Cloud.

Upsides

Humana's investment in Healthpilot enhances digital enrollment for Medicare options.

The company is the first insurer to cover TMS therapy for adolescent depression.

Humana's focus on value-based care aims to improve outcomes for kidney disease patients.

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