Behavioral Health Prior Authorization Nurse

Humana • Work at Home - Wisconsin, WI

4d • $71,100 - $97,800 • Remote

About The Position

Humana is seeking a Behavioral Health Prior Authorization Nurse to join the Wisconsin Medicaid Market (iCare) team. Reporting to the Supervisor of Pre-Authorization Nursing, 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/or Medicaid criteria to promote cost-effective delivery of health care services.

Requirements

• Unrestricted license as a Registered Nurse in the State of Wisconsin or compact state.
• Two (2) years of experience in Utilization Management.

Nice To Haves

• Experience with inpatient and outpatient reviews.
• 1 year of previous Mental/Behavioral Health experience.
• Experience working with MCG guidelines.
• Experience using TruCare.
• Health Plan experience working with large carriers.
• Previous Medicare/Medicaid experience.

Responsibilities

• Review authorization requests for inpatient and outpatient behavioral health care following applicable Medicare and Medicaid criteria, Humana/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.
• Use your skills to make an impact

Benefits

• medical
• dental
• 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

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level