Pre-Authorization Nurse

Humana • KY

82d • $71,100 - $97,800

About The Position

The Pre-Authorization Nurse reviews prior authorization and retro requests for appropriate care and setting, following guidelines and policies, and approves services or forwards requests to the appropriate stakeholder. The Pre-Authorization Registered Nurse work assignments are varied and frequently require interpretation and independent determination of the appropriate courses of action. The Pre-Authorization Registered 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 own work area professional concepts/standards, regulations, strategies and operating standards. Makes decisions regarding own work approach/priorities and follows direction. Work is managed and often guided by precedent and/or documented procedures/regulations/professional standards with some interpretation. Work hours will be Monday-Friday 9:00 AM - 6:00 PM EST with very limited rotating on-call coverage and oversight during weekends and holidays. Meet quarterly in Louisville, Ky office for meetings.

Requirements

• Licensed Registered Nurse (RN) in the state of Kentucky with no disciplinary action.
• Ability to hold licenses in multiple states without restriction.
• 3+ years of experience as a nurse in a clinical setting.
• Strong proficiency with MS Office Suite (Word, Excel, PowerPoint).
• Ability to learn multiple systems.

Nice To Haves

• Bachelor's Degree.
• 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 and HCG guidelines.

Responsibilities

• Review prior authorization and retro requests for appropriate care and setting.
• Approve services or forward requests to the appropriate stakeholder.
• Complete medical necessity and level of care reviews for requested services.
• Educate providers on utilization and medical management processes.
• Enter and maintain pertinent clinical information in various medical management systems.
• Make decisions regarding own work approach/priorities.

Benefits

• Medical, dental and vision benefits.
• 401(k) retirement savings plan.
• Paid time off, company and personal holidays, volunteer time off.
• 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: Bachelor's degree
• Number of Employees: 5,001-10,000 employees