Pre-Authorization Nurse

Position Overview

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

Employment Type

Full-time

Location Type

Remote, Work from Home

Required Qualifications

• 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.
• Intermediate to Advanced proficiency with MS Office applications, including Word, Excel (i.e., filter), and Outlook.
• Medicare/Medicaid experience.
• 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.

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.

Work Hours

• Monday – Friday 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.
• OneNote proficiency.

Work at Home Guidance

• Internet Service: Minimum download speed of 25 Mbps and upload speed of 10 Mbps is recommended. Wireless, wired cable, or DSL connection is suggested. Satellite, cellular, and microwave connections may be used only if approved by leadership.
• Internet Stipend: 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 the business requirements for the position.
• Work Environment: Must work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information.

Company Information

Humana CarePlus is more than a health plan; we are human care. Humana focuses on helping people achieve their best health. Our dedicated strategies across various markets and states are enabled by partnerships with state and local governments, community-based organizations, and national partners committed to removing barriers to helping people achieve their best health.

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.

Additional Information

• Travel: None.
• Language Proficiency Testing: Any Humana associate who speaks with a member in a language other than English must take a language proficiency assessment to ensure competency. Applicants will be required to take the Interagency Language Rating (ILR) test as provided by the Federal Government.