Pre-Authorization Registered Nurse

San Antonio, Texas, United States

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Not SpecifiedCompensation

Mid-level (3 to 4 years)Experience Level

Full TimeJob Type

UnknownVisa

Health Insurance, HealthcareIndustries

Requirements

Candidates must hold an active Licensed Registered Nurse (RN) license in Virginia or a compact license (eNLC) state with no disciplinary actions, and be eligible for licensure in multiple states. A minimum of two years of varied clinical nursing experience in an acute care, skilled, or rehabilitation setting is required, along with intermediate to advanced proficiency in Microsoft Office (Word, Excel, PowerPoint) and the ability to navigate multiple systems. Preferred qualifications include health plan experience with large carriers, previous Medicare/Medicaid experience, utilization management, case management, discharge planning, home health or rehab experience, and certification in Case Management (CCM) or Managed Care Nursing (CMCN).

Responsibilities

The Pre-Authorization Nurse 2 will review prior authorization requests for appropriate care and setting, approving services or forwarding them to the appropriate stakeholders based on guidelines and policies. This role involves completing medical necessity and level of care reviews using clinical judgment, educating providers on utilization and medical management processes, and maintaining clinical information in various medical management systems. The nurse will make independent decisions regarding work methods, often in ambiguous situations, requiring minimal direction and adherence to established guidelines.

Skills

Registered Nurse (RN)

Clinical Nursing

Acute Care

Skilled Nursing

Rehabilitation

Microsoft Office Suite

Microsoft Word

Microsoft Excel

Microsoft PowerPoint

System Navigation

Technical Troubleshooting

Health Plan Experience

Medicare

Medicaid

Medical Necessity Review

Utilization Review

Medical Management

Provider Education

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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