Pre-Authorization Nurse

Kentucky, United States

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Not SpecifiedCompensation

Mid-level (3 to 4 years)Experience Level

Full TimeJob Type

UnknownVisa

Health Insurance, HealthcareIndustries

Requirements

Candidates must be a Licensed Registered Nurse (RN) in Kentucky with no disciplinary action and possess the ability to hold licenses in multiple states without restriction. A minimum of 3 years of experience as a nurse in a clinical setting is required, along with strong proficiency in MS Office Suite (Word, Excel, PowerPoint) and the ability to learn multiple systems. Experience with policy and procedure development and implementation is also necessary. Preferred qualifications include a Bachelor's Degree, health plan experience with large carriers, previous Medicare/Medicaid experience, and prior utilization management, case management, discharge planning, or home health/rehab experience. Familiarity with MCG and HCG guidelines is a plus. Candidates must reside within a 2-hour driving distance of Louisville, Kentucky, and have a high-speed DSL or cable modem (25mbps download x 10mbps upload) for remote work, with satellite and wireless internet not permitted. They must also have a dedicated, interruption-free space to protect member PHI/HIPAA information.

Responsibilities

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. This role involves completing medical necessity and level of care reviews using clinical judgment, and referring cases to internal stakeholders as needed. The nurse will also educate providers on utilization and medical management processes and enter/maintain pertinent clinical information in various medical management systems. They will make decisions regarding their own work methods, occasionally in ambiguous situations, requiring minimal direction and following established guidelines/procedures.

Skills

Licensed Registered Nurse (RN)

Clinical setting experience

MS Office Suite

Word

Excel

PowerPoint

Policy and procedure development

Utilization management

Case management

Discharge planning

Home health

Rehab

MCG guidelines

HCG guidelines

Medicare

Medicaid

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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