RPh Operations Advisor - Aetna Medical Prior Authorizations
CVS HealthSalary not specified
Full Time
Mid-level (3 to 4 years), Senior (5 to 8 years)
Not SpecifiedCompensation
Senior (5 to 8 years)Experience Level
Full TimeJob Type
UnknownVisa
Health InsuranceIndustries
Requirements
Candidates must reside in Oklahoma and possess an unrestricted Registered Nurse license in Oklahoma. A minimum of 3 years of clinical nursing experience is required, along with intermediate to advanced proficiency in MS Office Suite (Word, Excel, PowerPoint, Teams) and the ability to quickly learn new systems and troubleshoot basic technical issues in a remote setting. The role also requires the ability to work independently under general instructions and as part of a team.
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 making independent determinations on appropriate courses of action, completing medical necessity and level of care reviews using clinical judgment, and referring cases to internal stakeholders as needed. Responsibilities include making and receiving an average of 50% of calls with providers, educating providers on utilization and medical management processes, and entering/maintaining clinical information in medical management systems.
Skills
Clinical Nursing
MS Office
Word
Excel
PowerPoint
Teams
Medical Necessity Review
Utilization Management
Case Management
Discharge Planning
Home Health
Medicare
Medicaid
Pre-authorization
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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