Humana Pre-Authorization Nurse, RN or LPN - Miami, FL in Miami, Florida
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.
This is an office based role, with eligibility to work at home once production measures are maintained.
The hours of this role are Mon-Fri, 8am-5pm est.
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.
Licensed RN or LPN in FL without restriction
Hospital experience with knowledge of adult patient continue of care
Acute UM experience or experience with medical necessity reviews for inpatient hospital admissions
Excellent computer skills and ability to easily navigate multiple applications
Ability to work independently under general instructions and with a team
Must have accessibility to high speed DSL or Cable modem for a home office (Satellite internet service is NOT allowed for this role); recommended speed is 10Mx1M
Health Plan experience working with large carriers
Previous Medicare/Medicaid experience a plus
Experience working with MCG or Interqual guidelines
Experience meeting or exceeding metrics
As part of our hiring process for this opportunity, we will be using a technology called Montage Voice which allows us to quickly connect and gain valuable information from you about your relevant experience.
If you are selected for a phone screen you will receive an email inviting you to participate in a Montage Voice interview. During this call you will be asked a set of questions pertaining to this particular role and you will provide recorded responses. The entire process takes about 15-20 minutes and can be done at your convenience. Your responses will be reviewed and you will be informed if you were selected for an in person or video interview, depending on your location.
Scheduled Weekly Hours
Equal Opportunity Employer
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