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 possess a Licensed Registered Nurse (RN) in Florida or a compact state without disciplinary action, and reside in NC, SC, FL, or GA. A minimum of 2 years of experience in Utilization Management (UM), Pre-Auth, or other managed care review is required, along with 1+ year of acute and/or critical care clinical experience. Proficiency in MS Office Word, Excel (including filtering), and Outlook is necessary. Preferred qualifications include a BSN, bilingual English/Spanish skills, health plan experience with large carriers, Medicare/Medicaid experience, and familiarity with CMS Guidelines, MCG, or Interqual guidelines. An internet download speed of at least 25 Mbps and an upload speed of 10 Mbps is recommended for remote work.

Responsibilities

The Pre-Authorization Nurse 2 is responsible for reviewing prior authorization requests to ensure appropriate care and setting, adhering to guidelines and policies. They will approve services or forward requests to the appropriate stakeholders, completing medical necessity and level of care reviews using clinical judgment. The role involves referring cases to internal stakeholders as needed, educating providers on utilization and medical management processes, and entering/maintaining clinical information in medical management systems. Communication with providers and members is also a key duty.

Skills

Licensed Registered Nurse (RN)

Utilization Management (UM)

Pre-Auth

Managed Care Review

Acute Care

Critical Care

MS Office Word

MS Excel

MS Outlook

Bilingual English/Spanish

Health Plan Experience

Medicare

Medicaid

CMS Guidelines

MCG Guidelines

Interqual Guidelines

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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