Humana Inc. (NYSE: HUM) is committed to putting health first – for our teammates, our customers and our company. Through our Humana insurance services and CenterWell healthcare services, we make it easier for the millions of people we serve to achieve their best health – delivering the care and service they need, when they need it. These efforts are leading to a better quality of life for people with Medicare, Medicaid, families, individuals, military service personnel, and communities at large.
Humana Healthy Horizons is seeking a Pre-Authorization Nurse 2 who will review prior authorization requests for appropriate care and setting, following guidelines and policies, and approves services or forwards requests to the appropriate stakeholder. The Pre-Authorization Nurse 2 completes medical necessity reviews for requested services using clinical judgment and refers to internal stakeholders for review depending on case findings.
Required Qualifications Active Oklahoma or Compact Registered Nurse, RN, license without restrictions or disciplinary action. Minimum Two (2) years clinical nursing experience in acute care, emergency room, ICU, skilled or rehabilitation setting. Working knowledge of MS Office including Word, Excel, PowerPoint, and Teams in a Windows based environment and an ability to quickly learn new systems and ability to troubleshoot and resolve basic technical difficulties in a remote environment. Ability to work independently under general instructions and with a team. Work Style: Remote Work at Home Location: Must reside in Oklahoma Training Schedule: Must be able to attend training schedule. Monday – Friday; 8:00am – 5:00pm Central Time Work Schedule: The department has multiple schedules available: Monday through Friday 8:00 AM – 5:00 PM Central Time with rotating holiday and weekend coverage as needed Travel: Minimal travel for office meetings 1-2 times annually as business needs. Work at Home Guidance 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 recommended; 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 Preferred Qualifications Previous Medicare/Medicaid experience a plus. Previous experience in utilization management, case management, discharge planning and/or home health or rehab. Certification in Case Management a plus (CCM). Experience working with MCG or Interqual guidelines. Triage experience a plus. Health Plan experience working with large carriers. Bilingual preferred.
Educates providers on utilization and medical management processes. Enters and maintains pertinent clinical information in the 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 document procedures, regulations or professional standards with some interpretation.
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