Humana is seeking a Behavioral Health Prior Authorization Nurse to join the Wisconsin Medicaid Market (iCare) team. You will review the clinical appropriateness of prior authorization (PA) requests. You will ensure that all benefits authorized meet medical necessity and other Medicare and Medicaid criteria to promote cost-effective delivery of health care services. Share your talents and develop your skills all while doing your part to improve the lives of others.
Essential Duties and Responsibilities:
- Review authorization requests for inpatient behavioral health care pursuant to applicable Medicare and Medicaid criteria, Humana/iCare guidelines, and PA Department policies and procedures.
- Provide complete and accurate documentation specifying rational for approval, or for forwarding to the CMO/Medical Director for further review.
- Create reduction/denial letters based on the CMO/Medical Director's review and applicable guidelines.
- Maintain a thorough understanding of Medicare and Medicaid guidelines and stay abreast of updates and changes.
- Work in collaboration with the PA staff to ensure timely completion of all workflows within the Department.
Use your skills to make an impact
Required Qualifications
- Unrestricted license as a Registered Nurse in the state of Wisconsin or compact state.
- One (1) year of experience in Utilization Management
- Two (2) years of experience in mental health and/or substance abuse rehabilitation.
- Available to work 8:30am-5pm in Central Standard Time (CST).
- Proficient with MS Office products including Word, Excel and Outlook.
Preferred Qualifications
- Previous experience in case management, discharge planning and/or home health or rehab.
- Experience working with MCG or InterQual guidelines.
- Health Plan experience working with large carriers.
- Previous Medicare/Medicaid experience.
Additional Information
- Workstyle: Home. Home workstyle is defined as remote but will use Humana office space on an as needed basis for collaboration and other face-to-face needs.
- Typical Work Days/Hours: Monday – Friday, 8:30am – 5:00 pm Central Standard Time (CST)
Work at Home Requirements: To ensure Home or Hybrid Home/Office employees’ ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office employees must meet the following criteria: At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is required; wireless, wired cable or DSL connection is suggested. In certain roles, the minimum recommended internet speed required by Humana may not be sufficient for business needs. Humana reserves the right to require associates to upgrade their internet service if necessary. Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information.Travel: While this is a remote position, occasional travel to Humana's offices for training or meetings may be required.
Scheduled Weekly Hours
40
Pay Range
The compensation range below reflects a good faith estimate of starting base pay for full time (40 hours per week) employment at the time of posting. The pay range may be higher or lower based on geographic location and individual pay will vary based on demonstrated job related skills, knowledge, experience, education, certifications, etc.
$71,100 - $97,800 per year
This job is eligible for a bonus incentive plan. This incentive opportunity is based upon company and/or individual performance.
Description of Benefits
Humana, Inc. and its affiliated subsidiaries (collectively, “Humana”) offers competitive benefits that support whole-person well-being. Associate benefits are designed to encourage personal wellness and smart healthcare decisions for you and your family while also knowing your life extends outside of work. Among our benefits, Humana provides medical, dental and vision benefits, 401(k) retirement savings plan, time off (including paid time off, company and personal holidays, paid parental and caregiver leave), short-term and long-term disability, life insurance and many other opportunities.
