Prior Authorization RN

Humana • Wyoming, MI

2d • $71,100 - $97,800 • Remote

About The Position

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.

Requirements

• 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

Nice To Haves

• 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

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.

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