Prior Authorization RN

Humana

3d•Remote

About The Position

Humana is seeking a Prior Authorization RN to join the Wisconsin Medicaid Market (iCare) team. This position reviews the clinical appropriateness of prior authorization (PA) requests and ensures that all benefits authorized meet medical necessity and other Medicare and/or Medicaid criteria if applicable, 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 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 inpatient and subacute activity 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. Use your skills to make an impact

Requirements

Licensed as a Registered Nurse in the State of Wisconsin, including compact license.
Two (2) or more years of experience in clinical care.
Proficiency with Microsoft Office applications, specifically Word, Excel, and Outlook.
Must be able to work the hours of 8:30-5 pm in Central Standard Time

Nice To Haves

Bachelor of Science in Nursing.
Experience with case management, discharge planning or prior authorization.
Knowledge of Milliman (MCG) or InterQual.
Knowledge of TruCare.
Managed Care experience.

Responsibilities

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 inpatient and subacute activity 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.