Humana is looking for a Prior Authorization RN to join the Wisconsin Medicaid Market (iCare) team. Reporting to the Utilization Management Supervisor, 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 if applicable, to promote cost-effective delivery of health care services. You will work from remotely from home. You will develop your skills all while doing your part to improve the lives of others.
Essential Duties and Responsibilities:- Review PA requests outpatient services according to applicable Medicare and Medicaid criteria, iCare guidelines, and PA Department 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 thoughtful understanding of Medicare and Medicaid guidelines and stay informed about changes.
- Work in collaboration with the PA staff to ensure completion of all workflows within the Department.
- Assist with program and procedure development for the PA Department.
- Lead or participate in special projects.
Required Qualifications- Licensed as a Registered Nurse in the State of Wisconsin, including compact license.
- Two (2) or more years of experience in clinical care.
- Work the hours of 8:30-5 pm in Central Standard Time
Preferred Qualifications- Bachelor of Science in Nursing
- 1 year of experience in Utilization Management
- Reside within the Central Standard or Eastern Standard time zones
- Knowledge of Milliman (MCG)
- Knowledge of TruCare
- Managed Care 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 Workdays/Hours: Monday through Friday, 8:30am - 5:00 pm Central Standard Time (CST)
WAH Internet StatementThe 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.
- Satellite, cellular and microwave connection can be used only if approved by leadership.
- Employees 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 employees with telephone equipment appropriate to meet the requirements for their position/job.
- Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information.
HireVueAs part of our hiring process for this opportunity, we will use an interviewing technology called HireVue to enhance our hiring. HireVue allows us to quickly connect and gain valuable information from you about your relevant experience at a time that is best for your schedule.
Travel: While this is a remote position, occasional travel to Humana's offices for training or meetings may be required.
Scheduled Weekly Hours40
Pay RangeThe 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 BenefitsHumana, 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, volunteer time off, paid parental and caregiver leave), short-term and long-term disability, life insurance and many other opportunities.
