Boston, MA, United States
Healthcare, Nursing, Project Management, Manager
Apr 28, 2023
The Senior 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. Makes decisions on moderately complex to complex issues regarding technical approach for project components, and work is performed without direction.
Senior Pre-Authorization Nurse:
Serves as a team lead and subject matter expert (SME) to assist with questions and mentoring of clinical staff
Reviews and resolves escalated issues received from other CarePlus departments
Leads implementation of process improvement initiatives based on data analysis and identified compliance and operational risks
Reviews inventory reports and assists management with data tracking to identify trends with specific authorization cases
Makes recommendations regarding training, improving outcomes, and process efficiencies.
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
Works with several internal stakeholders, medical directors, and leaders to help facilitate integrated care coordination and promote quality member outcomes
Begins to influence department's strategy.
Exercises considerable latitude in determining objectives and approaches to assignments
Implements and executes policies and processes necessary to support the business need and maintain compliance with regulatory requirements
Assists with other assignments and initiatives as assigned
3 years or more of varied nursing experience
Registered Nurse - active compact or single state RN in the state(s) in which the nurse is required to practice
2 or more years of utilization management experience
1 or more years of project management experience
Proficient with MS Office products including Word, Excel and Outlook
Must reside within the Eastern Time Zone
Health Plan experience working with large carriers
Previous Medicare/Medicaid experience
Experience working with MCG, InterQual guidelines and CMS guidelines
Experience with analyzing and extracting data from reports
Monday - Friday 8:00 a.m. - 5:00 p.m. EST and overtime based on business needs.
As part of our hiring process, we will be using an exciting interviewing technology provided by Modern Hire, a third-party vendor. This technology provides our team of recruiters and hiring managers an enhanced method for decision-making.
If you are selected to move forward from your application prescreen, you will receive correspondence inviting you to participate in a pre-recorded Voice Interview and/or an SMS Text Messaging interview. If participating in a pre-recorded interview, you will respond to a set of interview questions via your phone. You should anticipate this interview to take approximately 10-15 minutes.
If participating in a SMS Text interview, you will be asked a series of questions to which you will be using your cell phone or computer to answer the questions provided. Expect this type of interview to last anywhere from 5-10 minutes. Your recorded interview(s) via text and/or pre-recorded voice will be reviewed and you will subsequently be informed if you will be moving forward to next round of interviews.
Work at Home Guidance
To ensure Home or Hybrid Home/Office associates' ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office associates must meet the following criteria:
At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is recommended; wireless, wired cable or DSL connection is suggested
Satellite, cellular and microwave connection can be used only if approved by leadership
Associates who live and work from Home in the state of California, Illinois, Montana, or South Dakota will be provided a bi-weekly payment for their internet expense.
Humana will provide Home or Hybrid Home/Office associates with telephone equipment appropriate to meet the business requirements for their position/job.
Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information
Internal- If you have additional questions regarding this role posting, please send them to the Ask A Recruiter persona by visiting go/yammer and searching Ask A Recruiter! Please be sure to provide the requisition number so we may be able to research your request quicker.
Alert: Humana values personal identity protection. Please be aware that applicants selected for leader review may be asked to provide their social security number, if it is not already on file. When required, an email will be sent from Humana@myworkday.com with instructions on how to add the information into your official application on Humana's secure website.
Scheduled Weekly Hours
Humana complies with all applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, sexual orientation, gender identity or religion. We also provide free language interpreter services. See our https://www.humana.com/legal/accessibility-resources?source=Humana_Website.
Website : http://www.humana.com