Humana

About Humana

 

Job Category:

Member Quality & Financials - Utilization Management

Country:

United States

Postal Code:

33101

Approximate Salary:

Not Specified

Position Type:

Full Time

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RN/LPN Pre-Certification Nurse-2 - Doral FL 8 hr. 8:00AM-7:00PM

Humana - Miami, Florida

Posted: 10/11/2018

Description

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.

Responsibilities

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.

               

Required Qualifications

  • Active RN/LPN license in the state of Florida without restrictions 
  • 3 years minimum  of varied clinical nursing experience
  • Proficient with MS Office products including Word, Excel and Outlook
  • Ability to use multiple systems simultaneously
  • Ability to work independently under general instructions and with a team

Preferred Qualifications

  • Education: BSN or Bachelor's degree in a related field
  • 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
  • Experience working with MCG or Interqual guidelines
     

Additional Information

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

40

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