Experienced Pre-Authorization Registered Nurse – Remote Opportunity for Utilization Management and Medical Necessity Reviews

Introduction to Humana Inc. At Humana Inc., we are dedicated to putting health first for our teammates, customers, and the company as a whole. Through our comprehensive insurance services and CenterWell healthcare services, we strive to make it easier for millions of people to achieve their best health. Our mission is built on delivering the care and service needed, when it's needed, leading to a better quality of life for individuals with Medicare, Medicaid, families, and communities at large. Position Overview We are seeking an experienced Pre-Authorization Registered Nurse to join our team. As a Pre-Authorization Nurse, you will play a critical role in reviewing prior authorization requests, ensuring appropriate care and setting, and making informed decisions based on clinical judgment and guidelines. This position offers a unique opportunity to work remotely, with a schedule that includes Monday through Friday, 9:00 AM - 6:00 PM Eastern Time, and limited on-call coverage during weekends and holidays. Key Responsibilities: Review prior authorization requests for medical necessity and level of care, utilizing clinical judgment and adhering to established guidelines and policies. Approve services or forward requests to the appropriate stakeholders, ensuring timely and efficient decision-making. Complete medical necessity and level of care reviews for requested services, referring to internal stakeholders as needed. Educate providers on utilization and medical management processes, promoting best practices and optimal patient outcomes. Enter and maintain accurate and pertinent clinical information in various medical management systems, ensuring data integrity and compliance with regulatory requirements. Collaborate with internal stakeholders to develop and implement policies and procedures, driving continuous improvement and excellence in patient care. Essential Qualifications: To succeed in this role, you will need: A current license as a Registered Nurse (RN) in the state of Kentucky, with no disciplinary action and the ability to hold licenses in multiple states without restriction. A minimum of 3 years of experience as a nurse in a clinical setting, with a strong foundation in medical necessity and level of care reviews. Proficiency in MS Office Suite, including Word, Excel, and PowerPoint, with the ability to learn multiple systems and adapt to new technologies. Experience with the development and implementation of policies and procedures, with a focus on utilization management and medical necessity reviews. Preferred Qualifications: While not required, the following qualifications are preferred: A Bachelor's Degree in Nursing or a related field, with a focus on healthcare management or a related discipline. Health plan experience working with large carriers, with a strong understanding of Medicare and Medicaid regulations. Previous experience in utilization management, case management, discharge planning, and/or home health or rehab, with a focus on medical necessity and level of care reviews. Experience working with MCG and HCG guidelines, with a strong foundation in clinical decision-making and policy development. Skills and Competencies: To excel in this role, you will need: Strong clinical judgment and decision-making skills, with the ability to interpret complex medical information and make informed decisions. Excellent communication and interpersonal skills, with the ability to educate providers and collaborate with internal stakeholders. Proficiency in MS Office Suite, with the ability to learn multiple systems and adapt to new technologies. Strong analytical and problem-solving skills, with the ability to analyze complex data and develop creative solutions. A strong focus on patient-centered care, with a commitment to delivering high-quality services and promoting optimal patient outcomes. Career Growth Opportunities: At Humana, we are committed to supporting the career growth and development of our employees. As a Pre-Authorization Registered Nurse, you will have access to a range of training and development opportunities, including: Comprehensive orientation and onboarding program, with a focus on clinical decision-making and policy development. Ongoing training and education, with a focus on utilization management, medical necessity reviews, and healthcare regulations. Opportunities for professional growth and advancement, with a focus on leadership development and career progression. A supportive and collaborative work environment, with a focus on teamwork and open communication. Work Environment and Company Culture: At Humana, we are committed to creating a positive and inclusive work environment that supports the well-being and success of our employees. As a Pre-Authorization Registered Nurse, you will be part of a dynamic and supportive team, with access to a range of benefits and perks, including: Competitive salary and benefits package, with a focus on supporting the financial well-being of our employees. Opportunities for flexible work arrangements, including remote work and flexible scheduling. A comprehensive wellness program, with a focus on promoting physical and mental well-being. A supportive and inclusive company culture, with a focus on diversity, equity, and inclusion. Compensation and Benefits: We offer a competitive compensation package, with a salary range of $69,800 - $96,200 per year, depending on experience and qualifications. Our benefits package includes: Health benefits, effective day 1, with a focus on supporting the physical and mental well-being of our employees. Paid time off, holidays, volunteer time, and jury duty pay, with a focus on supporting work-life balance. Recognition pay, with a focus on rewarding and recognizing employee contributions and achievements. 401(k) retirement savings plan, with employer match, with a focus on supporting the financial well-being of our employees. Tuition assistance, scholarships for eligible dependents, and parental and caregiver leave, with a focus on supporting the educational and family needs of our employees. Conclusion: If you are a motivated and experienced Registered Nurse looking for a challenging and rewarding role, we encourage you to apply for this exciting opportunity. As a Pre-Authorization Registered Nurse at Humana, you will have the chance to make a real difference in the lives of our patients, while also advancing your career and developing your skills and expertise. Don't miss out on this opportunity to join our dynamic and supportive team – apply today! Apply for this job