The Pre-Authorization Nurse 1 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 1 work assignments are often straightforward and of moderate complexity.

Responsibilities

Humana Benefits - How we Value You
Benefits starting day 1 of employment
Competitive 401k match
Generous Paid Time Off accrual
Tuition Reimbursement
Parent Leave
Go365 perks for well-being

The Pre-Authorization Nurse 1 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.
• Must be passionate about contributing to an organization focused on continuously improving consumer experiences
• Must Reside in the state of Louisiana

Required Qualifications

• Active RN license in the state of Louisiana
• Ability to be licensed in multiple states without restrictions
• 3 or more years varied nursing experience
• Proficient with MS Office products including Word, Excel and Outlook
• Ability to work independently under general instructions and with a team
• Workstyle: Remote work at home
• Location: Must reside in Louisiana
• Travel: Must be willing to commute about 5-10% for annual meetings and any required onsite training as requested by the business.
• Hours: Must be able to work a 40 hour work week, Monday through Friday 8:00 AM to 5:00 PM Central Time, weekend and over-time may be requested to meet business needs.
• Training: January 9th 2023
• Humana and its subsidiaries require vaccinated associates who work outside of their home to submit proof of vaccination, including COVID-19 boosters. Associates who remain unvaccinated must either undergo weekly negative COVID testing OR wear a mask at all times while in a Humana facility or while working in the field.

Work-At-Home Requirements

• Must have the ability to provide a high speed DSL or cable modem for a home office. Associates or contractors who live and work from home in the state of California will be provided payment for their internet expense.
• A minimum standard speed for optimal performance of 25x10 (25mpbs download x 10mpbs upload) is required.
• Satellite and Wireless Internet service is NOT allowed for this role.
• A dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information

Preferred Qualifications

• Health Plan experience working with large carriers
• Compact nursing licensure
• 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 (CCM) or Managed Care Nursing (CMCN) a plus
• Experience working with MCG or Interqual guidelines

Additional Information

Section 1121 of the Louisiana Code of Governmental Ethics states that current or former agency heads or elected officials, board or commission members or public employees of the Louisiana Health Department (LDH) who work directly with LDH’s Medicaid Division cannot be considered for this opportunity. A separation of two (2) or more years from LDH is required for consideration. For more information please visit: Louisiana Board of Ethics (la.gov)

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Scheduled Weekly Hours

40