Pre-Authorization Nurse

Humana • Louisiana, MO

6d • $71,100 - $97,800 • Remote

About The Position

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.

Requirements

• 2+ years of RN experience
• Active RN license in the state of Louisiana
• Ability to be licensed in multiple states without restrictions
• Must be able to work: Mon-Fri, Tues-Sat. and Sun- Thurs roles for 8 hour shifts.
• Proficient with MS Office products including Word, Excel and Outlook
• Ability to work independently under general instructions and with a team

Nice To Haves

• Health Plan experience working with large carriers
• Previous Medicare/Medicaid experience
• Previous experience in utilization management, case management, discharge planning and/or home health or rehab
• Experience working with MCG or Interqual guidelines

Responsibilities

• Reviews prior authorization requests for appropriate care and setting, following guidelines and policies.
• Approves services or forwards requests to the appropriate stakeholder.
• 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.

Benefits

• medical
• dental
• 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

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: No Education Listed