Pre-Authorization Registered Nurse

Pre-Authorization Nurse 2

Position Overview

Become a part of our caring community and help us put health first. 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's work assignments are varied and frequently require interpretation and independent determination of the appropriate courses of action. The Pre-Authorization Nurse 2 completes medical necessity and level of care reviews for requested services using clinical judgment and refers to internal stakeholders for review depending on case findings.

Responsibilities

• Educates providers on utilization and medical management processes.
• Enters and maintains pertinent clinical information in various medical management systems.
• Understands department, segment, and organizational strategy and operating objectives, including their linkages to related areas.
• Makes decisions regarding own work methods, occasionally in ambiguous situations, and requires minimal direction and receives guidance where needed.
• Follows established guidelines/procedures.

Requirements

• Active Licensed Registered Nurse (RN) in the state of Virginia or obtain a license in a state that participates in the compact license (eNLC) with no disciplinary action.
• Ability to be licensed in multiple states without restrictions.
• Minimum two (2) years varied clinical nursing experience in an acute care, skilled, or rehabilitation setting.
• Intermediate to Advanced knowledge using Microsoft Office Word, Excel, PowerPoint, navigating multiple systems and platforms, and ability to troubleshoot and resolve basic technical difficulties in a remote environment.
• Ability to work independently under general instructions and with a team.

Preferred Qualifications

• Health Plan experience working with large carriers.
• Compact nursing licensure.
• Previous Medicare/Medicaid experience is a plus.
• Previous Occupational and Physical Therapy utilization review.
• Previous experience in utilization management, case management, discharge planning, and/or home health or rehab.
• Certification in Case Management (CCM) or Managed Care Nursing (CMCN).
• Experience working with MCG or Interqual guidelines.

Additional Information

• Employment Type: Full time
• Workstyle: Remote work at home
• Location: Virginia or reside in a state participating in a compact license (eNLC).
• Travel: Less than 5% for market meetings as business needs.
• Hours: Must be able to work 8 hours Monday through Friday between 8:00 AM to 5:00 PM Eastern. May be required to work rotating holidays or weekends as determined by business needs.

Work at Home Guidance

To ensure Home or Hybrid Home/Office employees’ ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office employees must meet the following criteria:

• A minimum download speed of 25 Mbps and an upload speed of 10 Mbps is required.
• Wireless, wired cable, or DSL connection is required.
• Satellite, cellular, and microwave connection can be used only if approved by leadership.
• Employees 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 employees 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.

SSN Alert

Humana values personal identity protection. Please be aware that applicants may be asked to provide their Social Security Number, if it is not already on file. When required, an email will be sent from Humana@myworkday.com with instructions on how to add the information into your official application on Humana’s secure website.

Interview Format

As part of our hiring process for this opportunity, we will be using an interviewing technology called HireVue to enhance the interview process.