Pre-Authorization Nurse

About the Role

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 forwards requests to the appropriate stakeholder.

The Pre-Authorization Nurse 2 work assignments are varied and frequently require interpretation and independent determination of the appropriate courses of action. 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 department, segment, and organizational strategy and operating objectives, including their linkages to related areas. Makes decisions regarding own work methods, occasionally in ambiguous situations, and requires minimal direction and receives guidance where needed. Follows established guidelines/procedures.

Use your skills to make an impact.

Required Qualifications

• Licensed Registered Nurse (RN) in the state of Kentucky with no disciplinary action and ability to hold licenses in multiple states without restriction
• Minimum 3 years of experience as a nurse in a clinical setting
• Strong Proficiency with MS Office Suite (Word, Excel, Power Point) and ability to learn multiple systems
• Experience with the development and implementation of policies and procedures

Preferred Qualifications

• Bachelor's Degree
• Health Plan experience working with large carriers
• Previous Medicare/Medicaid experience a plus
• Previous experience in utilization management, case management, discharge planning and/or home health or rehab
• Experience working with MCG and HCG guidelines

Workstyle & Location

• Employment Type: Full time
• Workstyle: Remote Work at Home
• Location: Must reside within a 2-hour driving distance of Louisville, Kentucky office to attend meetings and trainings as needed.
• Schedule: Must be available Monday-Friday 9:00 AM - 6:00 PM Eastern Time with very limited rotating on-call coverage and oversight during weekends and holidays.
• Travel: Meet quarterly in Louisville office for meetings. While this is a remote position, occasional travel to Humana's offices for training or meetings may be required.

Work At Home Requirements

• Must have the ability to provide a high-speed DSL or cable modem for a home office. Associates or contractors who live and work from home in the state of California will be provided payment for their internet expense.
• A minimum standard speed for optimal performance of 25x10 (25mbps download x 10mbps upload) is required.
• Satellite and Wireless Internet service is NOT allowed for this role.
• A dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information.

Interview Process

• As part of our hiring process for this opportunity, we will be using an interviewing technology called HireVue to enhance our hiring and decision-making ability. HireVue allows us to quickly connect and gain valuable information from you pertaining to your relevant skills and experience at a time that is best for your schedule.

SSN Alert

• Humana values personal identity protection. Please be aware that applicants may be asked to provide their Social Security Number, if it is not already on file. When required, an email will be sent from Humana@myworkday.com with instructions on how to add the information into your official application on Humana’s secure website.

Compensation

• Scheduled Weekly Hours: 40
• Pay Range: The compensation range below reflects a good faith estimate of starting base pay for full time (40 hours per week) employment at the time of posting. The pay range may be higher or lower based on geographic location and individual pay will vary based on demonstrated job related skills, knowledge, experience, edu.