UM Nurse Pre-auth

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 forward 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. Educate providers on utilization and medical management processes. Enter and maintain 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. Follow established guidelines/procedures.

• Multi State RN license

• A minimum of three (3) years varied nursing experience

• Active RN license in the state(s) in which the nurse is required to practice

• Ability to be licensed in multiple states without restrictions

• Proficient with MS Office products including Word, Excel and Outlook

• Ability to work independently under general instructions and with a team

• Must be passionate about contributing to an organization focused on continuously improving consumer experiences

• Health Plan experience working with large carriers

• Previous Medicare/Medicaid experience a plus

• Previous experience in utilization management, case management, discharge planning and/or home health or rehab

• Experience working with MCG or Interqual guidelines

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.

• 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.

As part of our hiring process for this opportunity, we will be using an interviewing technology called Hire Vue to enhance our hiring and decision-making ability. Hire Vue allows us to quickly connect and gain valuable information from you pertaining to your relevant skills and experience at a time that is best for your schedule.

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  with instructions on how to add the information into your official application on Humana’s secure website.

Travel:
While this is a remote position, occasional travel to Humana's offices for training or meetings may be required.

40

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.

Humana, Inc. and its affiliated…