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
Required Qualifications
- 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
Preferred Qualifications
- 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.
Additional Information
- 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!
Additional Information
- Workstyle: Home: Associates Home office environment is their primary work location, but they will use Humana office space on an as needed basis for collaboration and other face-to-face needs.
- Work Location: Wisconsin
- Typical Work Days/Hours: Monday through Friday, 8:30 am – 5:00 pm CST
- 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.
Scheduled Weekly Hours
40Pay Range
The compensation range below reflects a good faith estimate of starting base pay for full time (40 hours per week) employment at the time of posting. The pay range may be higher or lower based on geographic location and individual pay will vary based on demonstrated job related skills, knowledge, experience, education, certifications, etc.
Description of Benefits
Humana, Inc. and its affiliated subsidiaries (collectively, “Humana”) offers competitive benefits that support whole-person well-being. Associate benefits are designed to encourage personal wellness and smart healthcare decisions for you and your family while also knowing your life extends outside of work. Among our 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.Application Deadline: 01-14-2026About us
Humana Inc. (NYSE: HUM) is committed to putting health first – for our teammates, our customers and our company. Through our Humana insurance services and CenterWell healthcare services, we make it easier for the millions of people we serve to achieve their best health – delivering the care and service they need, when they need it. These efforts are leading to a better quality of life for people with Medicare, Medicaid, families, individuals, military service personnel, and communities at large.
Equal Opportunity Employer
It is the policy of Humana not to discriminate against any employee or applicant for employment because of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or protected veteran status. It is also the policy of Humana to take affirmative action, in compliance with Section 503 of the Rehabilitation Act and VEVRAA, to employ and to advance in employment individuals with disability or protected veteran status, and to base all employment decisions only on valid job requirements. This policy shall apply to all employment actions, including but not limited to recruitment, hiring, upgrading, promotion, transfer, demotion, layoff, recall, termination, rates of pay or other forms of compensation and selection for training, including apprenticeship, at all levels of employment.
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What We Do
At Humana, our cultural foundation is aligned to helping members achieve their best health by delivering personalized, simplified, whole-person healthcare experiences. Recognizing healthcare needs continue to evolve for each person, for each family and for each community, Humana continuously creates innovative solutions and resources that help people live their healthiest lives on their terms –when and where they need it. Our employees are at the heart of making this happen and that’s why we are dedicated to building an organization of dynamic talent whose experience and passion center on putting the customer first.
