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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.

Work Days/Hours: Tuesday-Saturday 8am-5pm EST with overtime subject to business needs.

Responsibilities

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.

• 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.

Required Qualifications

• Bachelor's degree (BSN)

• Active RN license in FL or Compact RN license

• 1 or more years of utilization management experience

• 3 or more years of varied clinical nursing experience

Preferred Qualifications

• 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/or CMS guidelines

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

• Bilingual in English/Spanish

Additional Information

Work Days/Hours: Tuesday-Saturday 8am-5pm EST with overtime subject to business needs.

Additional Information
As part of our hiring process, we will be using an exciting interviewing technology provided by Modern Hire, a third-party vendor. This technology provides our team of recruiters and hiring managers an enhanced method for decision-making.

If you are selected to move forward from your application prescreen, you will receive correspondence inviting you to participate in a pre-recorded Voice Interview and/or an SMS Text Messaging interview. If participating in a pre-recorded interview, you will respond to a set of interview questions via your phone. You should anticipate this interview to take approximately 10-15 minutes.

If participating in a SMS Text interview, you will be asked a series of questions to which you will be using your cell phone or computer to answer the questions provided. Expect this type of interview to last anywhere from 5-10 minutes. Your recorded interview(s) via text and/or pre-recorded voice will be reviewed and you will subsequently be informed if you will be moving forward to next round of interviews.

Work at Home Guidance

To ensure Home or Hybrid Home/Office associates’ ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office associates must meet the following criteria:

• At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is recommended; wireless, wired cable or DSL connection is suggested

• Satellite, cellular and microwave connection can be used only if approved by leadership

• Associates 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 associates 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

Internal- If you have additional questions regarding this role posting, please send them to the Ask A Recruiter persona by visiting go/yammer and searching Ask A Recruiter! Please be sure to provide the requisition number so we may be able to research your request quicker.

Alert: Humana values personal identity protection. Please be aware that applicants selected for leader review may be asked to provide their social security number, if it is not already on file. When required, an email will be sent from [email protected] with instructions on how to add the information into your official application on Humana’s secure website.

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#LI-Remote

This is remote position.

Scheduled Weekly Hours

40