San Juan, PR, United States
Healthcare, Nursing, Bilingual, Case Management
Nov 20, 2020
Pre-Authorization Nurse 2 - Work at Home from PR ONLY
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.
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.
Registered Nurse from an accredited institution
Active RN license without restrictions in Puerto Rico
Affiliated with the CPEPR (Colegio de Profesionales de Enfermería de Puerto Rico)
Prior clinical experience in an acute care, skilled nursing, rehabilitation, OR discharge planning
WAH requirements: Must have the ability to provide a high speed DSL or cable modem for a home office (Satellite and Wireless Internet service is NOT allowed for this role). A minimum standard speed for optimal performance of 10x1 (10mbs download x 1mbs upload) is required. A dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information
Health Plan experience
Previous Case Management Experience
Call center or triage experience
Previous experience managing Medicare members
Bilingual English/Spanish. Candidate selected will not be communicating in English with members.
Monday to Friday 8:30AM - 5:30PM, overtime
Work At Home from PR Only . Office is located at:
383 Ave FD Roosevelt | San Juan, PR, 00918-2131
Training: 6 months on site
ON CALL - Availability
Scheduled Weekly Hours
Website : http://www.humana.com