Location
Milford, OH, United States
Posted on
Oct 25, 2022
Profile
Description
Humana Healthy Horizons is seeking a Pre-Authorization Nurse 1 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 1 work assignments are often straightforward and of moderate complexity.
Responsibilities
The Pre-Authorization Nurse 1 completes medical necessity 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.
Required Qualifications
Must live in the state of Ohio.
An active RN or LPN license in the state of Ohio without disciplinary action.
Two (2) or more years clinical nursing experience in acute care, emergency room, ICU, skilled or rehabilitation setting.
Intermediate experience or working knowledge of Microsoft Office programs, specifically Excel, PowerPoint, Outlook, and Word, systems and platforms.
Ability to troubleshoot and resolve general technical difficulties.
Ability to work independently under general instructions and with a team.
Must have the ability to provide a high speed DSL or cable modem for a home office.
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.
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.
Bilingual is a plus.
Additional Information
Work Style: Remote (Work at Home) in Ohio.
Training: Must be able to attend training schedule. Monday - Friday; 8:00am - 5:00pm EST.
Work Hours & On-Call Schedule: Regular working hours will be a 40 hours/week; Monday - Friday with rotating weekends/Saturdays (approximately every 6 weeks) standard day hours. On-Call Sunday morning (approximately every 6 weeks).
Interview Format
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.
Scheduled Weekly Hours
40
Humana complies with all applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, sexual orientation, gender identity or religion. We also provide free language interpreter services. See our ****
Company info
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