Pre-Authorization Nurse

Florida, United States

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Not SpecifiedCompensation

Mid-level (3 to 4 years), Senior (5 to 8 years)Experience Level

Full TimeJob Type

UnknownVisa

Health Insurance, Managed CareIndustries

Requirements

Candidates must be a Licensed Registered Nurse (RN) in Florida or a compact state with no disciplinary action and reside in NC, SC, FL, or GA. Required experience includes working with CMS Guidelines, MCG and/or InterQual guidelines, 2+ years of Utilization Management (UM), Pre-Auth, and/or other managed care review experience, and 1+ year of acute and/or critical care clinical experience. Medicare/Medicaid experience and intermediate to advanced proficiency with MS Office applications (Word, Excel, Outlook) are also necessary. The role requires availability for either Tuesday-Saturday or Monday-Friday shifts, including overtime and holidays, and experience working collaboratively across multiple functional areas, fostering teamwork, and utilizing data and analytical thinking.

Responsibilities

The Pre-Authorization Nurse will review prior authorization requests for appropriate care and setting according to guidelines and policies, approving services or forwarding requests as needed. Responsibilities include completing medical necessity and level of care reviews using clinical judgment, referring cases to internal stakeholders, and educating providers on utilization and medical management processes. The nurse will also enter and maintain pertinent clinical information in various medical management systems and communicate with providers or members.

Skills

Registered Nurse (RN)

CMS Guidelines

MCG Guidelines

InterQual guidelines

Utilization Management (UM)

Pre-Auth

Managed care review

Acute care

Critical care

Medicare

Medicaid

MS Office

Excel

Outlook

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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