The Pre-Authorization Nurse reviews prior authorization requests for appropriate care and setting, following guidelines and policies, and approves services or forward requests to the appropriate stakeholder. The Pre-Authorization Nurse work assignments are varied and frequently require interpretation and independent determination of the appropriate courses of action.
The Pre-Authorization Nurse 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.
- 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.
Use your skills to make an impact
Required Qualifications
- 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
- Minimum two, (2) years varied clinical nursing experience in an acute care, skilled or rehabilitation setting
- Previous experience in utilization management, case management, discharge planning and/or home health or rehab
- 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
- Previous Medicare/Medicaid experience
- Certification in Case Management (CCM) or Managed Care Nursing (CMCN)
- Experience working with MCG or Interqual guidelines
Additional Information
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 Requirements: 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: At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is required; wireless, wired cable or DSL connection is suggested. In certain roles, the minimum recommended internet speed required by Humana may not be sufficient for business needs. Humana reserves the right to require associates to upgrade their internet service if necessary. Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information.
Travel: While this is a remote position, occasional travel to Humana's offices for training or meetings may be required.
Scheduled Weekly Hours
40
Pay Range
The compensation range below reflects a good faith estimate of starting base pay for full time (40 hours per week) employment at the time of posting. The pay range may be higher or lower based on geographic location and individual pay will vary based on demonstrated job related skills, knowledge, experience, education, certifications, etc.
$71,100 - $97,800 per year
This job is eligible for a bonus incentive plan. This incentive opportunity is based upon company and/or individual performance.
Description of Benefits
Humana, Inc. and its affiliated subsidiaries (collectively, “Humana”) offers competitive benefits that support whole-person well-being. Associate benefits are designed to encourage personal wellness and smart healthcare decisions for you and your family while also knowing your life extends outside of work. Among our benefits, Humana provides medical, dental and vision benefits, 401(k) retirement savings plan, time off (including paid time off, company and personal holidays, paid parental and caregiver leave), short-term and long-term disability, life insurance and many other opportunities.
