Pre-Authorization Nurse Supervisor

Humana

6d • Remote

About The Position

Become a part of our caring community and help us put health first Ready to make a real impact? As our Pre-Authorization Nursing Supervisor, you’ll lead the way in helping members get the care they need, when they need it. You’ll oversee the PA staff who process service requests, make important decisions, and work closely with a great team to keep things running smoothly. If you’re a nurse who loves collaborating, problem-solving, and making a difference, this is a fantastic opportunity to grow your career in a supportive environment. Come join us and help shape the future of care!

Requirements

• Licensed as a Registered Nurse in the State of Wisconsin, including compact license.
• Four (4) or more years of experience in clinical care.
• Proficiency with Microsoft Office applications, specifically Word, Excel, and Outlook.
• At least 3-years' experience with prior authorization/ utilization management.
• Previous leadership experience.

Nice To Haves

• Bachelor of Science in Nursing.
• Knowledge of Milliman (MCG) or InterQual.
• Knowledge of TruCare.
• Managed Care experience.

Responsibilities

• Provide day to day support to the UM/PA staff
• Perform monthly 1:1 check in with staff
• Maintain staff training material and resources
• Coordinate letter template updates (CMS and DHS requirements) with Compliance, NetDev, and IT to ensure the most current templates are available in TruCare and are used appropriately by PA Staff
• Intermediate-level support during NCQA re-accreditation, including implementing updated process and policies necessary to meet NCQA standards.
• Assist with leading bi-weekly department/ team meetings
• Review PA requests for home health services, durable medical equipment, outpatient therapies, skilled nursing facility therapies, and all outpatient procedures pursuant to applicable Medicare and Medicaid criteria, iCare guidelines, and PA Department policies and procedures.
• Review PA requests for inpatient medical stays, skilled nursing facility stays, long term acute hospital stays, inpatient rehabilitation facility stays per Humana/iCare’s inpatient work processes and participates with facility discharge planners, Care Coordinators/Care Managers and the behavioral health personnel in coordinating the member’s discharge needs.
• Monitors outpatient and behavioral health activities daily for outcomes related to readmission, utilization, quality of care and provider performance in compliance with Humana/iCare policies.
• 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 and efficient completion of all workflows within the Department.
• Assists with program and policy and procedure development for the PA Department.
• Lead or participate in special projects.

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.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: No Education Listed
• Number of Employees: 5,001-10,000 employees