Prior Authorization RN

Become a part of our caring community and help us put health first

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.

• 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 in a challenging and rewarding environment that helps improve the lives of terminal patients and communities.

• 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

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

• 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)
• Benefits:
  Benefits are effective on day 1. Full time Associates enjoy competitive pay and a comprehensive benefits package that includes: 401k, Medical, Dental, Vision and a variety of supplemental insurances, tuition assistance and much more!

Wisconsin

To ensure Home or Hybrid Home/Office employees’ ability to work effectively, the 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 business requirements for their position/job. Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information.

As part of our hiring process for this opportunity, we will be using an interviewing…