Pre-Authorization Nurse

Employment Type: Full time

Position Overview

Humana CarePlus is seeking a Pre-Authorization Nurse to review prior authorization requests for appropriate care and setting, following guidelines and policies, and approving services or forwarding requests to the appropriate stakeholder. Humana focuses on helping people achieve their best health through dedicated strategies and partnerships.

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.
• Communicates with providers or members.

Requirements

• 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.

Work Schedule

• Required Work Hours: Tuesday – Saturday 8am-5pm EST.
• Overtime and Holidays based on business needs.

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).
• Health Plan experience working with large carriers.
• Proficiency with OneNote.

Work at Home Guidance

• Internet Service: Minimum download speed of 25 Mbps and upload speed of 10 Mbps recommended. Wireless, wired cable, or DSL connection suggested. Satellite, cellular, and microwave connections may be used only if approved by leadership.
• Internet Expense: Associates living and working from Home in California, Illinois, Montana, or South Dakota will be provided a bi-weekly payment for their internet expense.
• Equipment: Humana will provide telephone equipment appropriate to meet business requirements.
• Work Environment: Must 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.

Benefits

• Benefits are effective on day 1.
• Full-time associates enjoy competitive pay and a comprehensive benefits package including:
  • 401k
  • Medical, Dental, Vision
  • Variety of supplemental insurances
  • Tuition assistance
  • And much more.

Language Proficiency Testing

Any Humana associate who speaks with a member in a language other than English must take a language proficiency assessment provided by an outside vendor to ensure competency. Applicants will be required to take the Interagency Language Rating (ILR) test as provided by the Federal Government.