RN - Prior-Authorization - Medicaid - Louisville KY

Profile

Description

The Pre-Authorization Nurse reviews prior authorization requests for appropriate care and setting, following guidelines and policies, and approves services or forward requests to the appropriate stakeholder for Humana's Kentucky Medicaid Plan. The Pre-Authorization Nurse work assignments are often straightforward and of moderate complexity.

Responsibilities


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


Licensed Registered Nurse (RN) in the state of Kentucky with no disciplinary action and ability to hold licenses in multiple states without restriction.
2 years of progressive clinical experience preferably in an acute care, skilled or rehabilitation clinical setting
Experience with the development and implementation of policies and procedures
Ability to work independently under general instructions and with a team
Strong Proficiency with MS Office Suite to include Word, Excel, Power Point,
Ability to troubleshoot and resolve system platform and connectivity problems related to work at home
Ability to work Monday-Friday 9am-6pm; rotating on-call coverage and oversight during weekends and holidays
This role may require limited travel (less than 10%) to support business needs


Preferred Qualifications


Bachelor's Degree
Certified Case Manager (CCM)
Claims or authorization experience
MCG experience
Care Management experience in an acute care, skilled or Rehabilitation clinical setting
Health Plan experience
Medicaid experience
Call center or triage experience
Bilingual


Work At Home Requirements


Must have a separate room with a locked door that can be used as a home office to ensure you and your members have absolute and continuous privacy while you work.
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.


In order to support the CDC recommendations on social distancing and reduce health risks for associates, members and public health, Humana is deploying virtual and video technologies for all hiring activities. This position may be subject to temporary work at home requirements for an indefinite period of time. These requirements include access to a personal computing device with a camera, a minimum internet connection speed of 10m x 1m, and a dedicated secure home workspace for interview or work purposes. Humana continues to monitor the situation, and will adjust service levels as the coronavirus situation evolves. The following changes are temporary and will be evaluated frequently with the goal of returning to normal operations as soon as possible. Your Talent Acquisition representative will advise on the latest recommendations to protect your health and wellbeing during the hiring process. #ThriveTogether #WorkAtHome

Interview Format

As part of our hiring process for this opportunity, we will be using an exciting interviewing technology called Modern Hire Voice to enhance our hiring and decision-making ability. Modern Hire Voice allows us to quickly connect and gain valuable information from you pertaining to your relevant skills and experience at a time that is best for your schedule.

If you are selected for a first round interview, you will 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 in a Modern Hire Voice interview. In this interview, you will listen to a set of interview questions over your phone and you will provide recorded responses to each question. You should anticipate this interview to take about 15-30 minutes. Your recorded interview will be reviewed and you will subsequently be informed if you will be moving forward to next round of interviews.

Scheduled Weekly Hours

40

Company info

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