The Pre-Authorization Nurse 1 reviews 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 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.
Required Qualifications
Active Registered Nurse, RN, license in the state of Ohio with no disciplinary action
3 or more years nursing experience in acute care, emergency room, ICU, skilled or rehabilitation setting.
Intermediate or better working knowledge using Microsoft Office Programs specifically Teams, Excel, PowerPoint, Outlook and Word, systems, platforms, and an ability to troubleshoot and resolve general technical difficulties
Ability to work independently under general instructions and with a team
Must be passionate about contributing to an organization focused on continuously improving consumer experiences
Additional Requirements/Adherence
Work Style:
Remote work at home
Preferred Location:
Ohio
Alternate Locations:
Kentucky, Indiana, Pennsylvania, West Virginia, Michigan,
Hours:
Leader will discuss this in more detail during interview
Must be able to attend training schedule between 8:00 AM and 5:00 PM Eastern Monday through Friday
Regular working hours will be a 40 hour work week Monday through Friday
Rotating weekends/Saturdays (approximately every 6 weeks) standard day hours
On-Call Sunday morning (approximately every 6 weeks)
Work At Home Requirements
Must have a separate room with a locked door that can be used as a home office to ensure absolute and continuous privacy during while you work
Must have accessibility to hardwired high speed internet with minimum speeds of 25Mx10M for a home office (Wireless and Satellite are prohibited)
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
Interview Format
As part of our hiring process for this opportunity, we will be using an exciting screening and interviewing technology called Modern Hire to enhance our hiring and decision-making ability. We use this technology to gain valuable information from you pertaining to your relevant skills and experience at a time that is best for your schedule.
You will be able to respond to the recruiters preferred response method via text, video or voice technologies If you are selected for a screen, you may receive an email correspondence (please be sure to check your spam or junk folders often to ensure communication isn't missed) inviting you to participate. You should anticipate this screen to take about 15 to 30 minutes. Your recorded screen will be reviewed and you will subsequently be informed if you will be moving forward to next round of interviews.
Covid Compliance Policy
For this job, associates are required to be fully COVID vaccinated, including booster or undergo weekly COVID testing and wear a face covering while at work. The weekly testing will need to be done through an approved Humana vendor, and unvaccinated associates should follow all social distancing and masking protocols if they are required to come into a Humana facility or work outside of their home. We are a healthcare company committed to putting health and safety first for our members, patients, associates, and the communities we serve.
If progressed to offer, you will be required to:
Provide proof of full vaccination, including booster or commit to testing protocols
OR
Provide proof of applicable exemption including any required supporting documentation
Medical, religious, state and remote-only work exemptions are available.
Employer job 
90 Day Old Job 
