Pre-Authorization Nurse

About Humana CarePlus

Become a part of our caring community and help us put health first. Humana CarePlus is more than a health plan. We’re human care. Humana focuses on helping people achieve their best health. Our dedicated strategies across various markets and states are enabled by partnerships with state and local governments, community-based organizations, and national partners committed to removing barriers to helping people achieve their best health.

Role Overview

Humana CarePlus is seeking a Pre-Authorization Nurse who reviews prior authorization requests for appropriate care and setting, following guidelines and policies, and approves services or forward requests to the appropriate stakeholder.

Responsibilities

• Completes medical necessity and level of care reviews for requested services using clinical judgment.
• 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.
• Communicate with providers or members.

Required Qualifications

• Licensed Registered Nurse (RN) in either Florida or a compact state with no disciplinary action.
• Must reside in NC, SC, FL or GA.
• Experience working with CMS Guidelines, MCG and/or InterQual guidelines.
• 2+ years of Utilization Management (UM), Pre-Auth, and/or other managed care review experience.
• 1+ years of acute and/or critical care clinical experience.
• Medicare/ Medicaid experience.
• Intermediate to Advanced proficiency with MS Office applications, including Word, Excel (i.e. filter) and Outlook.
• Experience working collaboratively across multiple functional areas and fostering teamwork.
• Excellent communication skills (written, oral, and presentation skills).
• Ability to use data and analytical thinking to make fact-based decisions and/or recommendations.

Preferred Qualifications

• Bachelor of Science in Nursing (BSN).
• Bilingual English/Spanish (must be able to speak, read and write in both languages without limitations or assistance, see Additional Information on testing).
• Health Plan experience working with large carriers.
• OneNote.

Work Hours

• Required Work Hours: There are two different work hour shifts for this position:
  • Tuesday – Saturday 8am-5pm EST, Overtime and Holidays based on business needs
  • OR
  • Monday – Friday 8am-5pm EST, Overtime and Holidays based on business needs.
• You must be available for either shift.

Work at Home Guidance

• To ensure Home or Hybrid Home/Office associates’ ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office associates must meet the following criteria:
  • At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is recommended; wireless, wired cable or DSL connection is suggested.
  • Satellite, cellular and microwave connection can be used only if approved by leadership.
• 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 requirements for their position/job.
• Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information.

Additional Information

• Workstyle: Remote, work from home.
• Travel: None
• Core Workdays & Hours: Tuesday – Saturday 8am-5pm EST, Overtime and Holidays based on business needs - OR - Monday – Friday 8am-5pm EST, Overtime and Holidays based on business needs.
• Benefits: Benefits are effective on day 1. Full time Associates enjoy competitive pay and a comprehensive benefits.