Louisville, Kentucky-based Humana is a leading healthcare company that offers a variety of health, wellness, and insurance products and services designed to off
Pre-Authorization Nurse
Location
United States + 9 moreAll locations: United States | United Kingdom | Canada | Germany | France | India | Brazil | Australia | Estonia | Japan
Posted
40 days ago
Salary
$71.1K - $97.8K / year
Seniority
Mid Level
No structured requirement data.
Job Description
Pre-Authorization Nurse
Humana
Role Description 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. The Pre-Authorization Nurse 2 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 - Send and receive telephonic calls averaging 50% communication with providers - Educate providers on utilization and medical management processes - Enter and maintain pertinent clinical information in various medical management systems - Understand own work area professional concepts/standards, regulations, strategies and operating standards - Make decisions regarding own work approach/priorities and follow direction - Work is managed and often guided by precedent and/or documented procedures/regulations/professional standards with some interpretation Qualifications - Must reside in Oklahoma - Registered Nurse, compact nursing license - 3+ years of clinical nursing experience - Intermediate to Advanced knowledge of MS Office including Word, Excel, PowerPoint, and Teams in a Windows based environment - Ability to quickly learn new systems and troubleshoot basic technical difficulties in a remote environment - Ability to work independently under general instructions and with a team Requirements - Health Plan experience working with large carriers (preferred) - Previous Medicare/Medicaid experience a plus (preferred) - Previous experience in pre-authorization, utilization management, case management, discharge planning and/or home health or rehab (preferred) - Experience working with MCG or Interqual guidelines (preferred) Benefits - Paid time off, holidays, volunteer time and jury duty pay - Recognition pay - 401(k) retirement savings plan with employer match - Tuition assistance - Scholarships for eligible dependents - Parental and caregiver leave - Employee charity matching program - Network Resource Groups (NRGs) - Career development opportunities
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