The Manager, Pre-Authorization Nursing 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. Decisions are typically related to resources, approach, and tactical operations for projects and initiatives involving own departmental area. Requires cross departmental collaboration, and conducts briefings and area meetings; maintains frequent contact with other managers across the department.
- Licensed Registered Nurse (RN) in the state of Florida with no disciplinary action.
- 2+ years of management/leadership experience, including experience with hiring, training, coaching and up to termination.
- Previous experience in utilization management, case management, discharge planning and/or home health or rehab.
- Progressive clinical experience preferably in a clinical setting.
- Able to give direction and make sound business decisions.
- Strong attention to detail.
- Exceptional verbal and written communication skills.
- Ability to work independently under general instructions and with a team.
- Strong Proficiency with MS Office Suite to include Word, Excel, Power Point.
- Must be passionate about contributing to an organization focused on continuously improving consumer experiences.
- Work at Home 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 10×1 (10mbs download x 1mbs upload) is required. A dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information
- Health Plan experience
- Experience working with MCG or Interqual guidelines
- Prior Medicare / Medicaid experience
- Fully Bilingual English/Spanish. Must be able to speak, read and write in both languages without limitations or assistance. If selected for the position, you will be required to take a Language Proficiency Assessment in English/Spanish. See Additional Information on testing.
Schedule: Monday- Friday, 8 am to 5 pm, with necessary overtime as the business demands for it. Saturday rotation with four other supervisors/managers.
Training: Virtual training, approximately 3 months.
Work Location (Address): This permanent job is working from Home temporary due to Covid 19 emergency. This position will deploy to the following location at a future date: 11430 N W 20th Street
Suite 300. Miami, FL 33172 CarePlus Doral office (once re-entry occurs) with the flexibility of working from home twice a week.
# of Direct Reports: 3 supervisors all which have direct reports under them.
- If Bilingual – Language Proficiency Testing: Any Humana associate who speaks with a member in a language other than Spanish and/or English must take a language proficiency assessment, provided by an outside vendor, to ensure competency. Applicants will be required to take the Interagency Language Rating (ILR) test as provided by the Federal Government
Scheduled Weekly Hours