Prior Authorization RN

Profile

Description

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.

Responsibilities

The Prior Authorization RN completes medical necessity and level of care reviews for requested services using clinical judgement and works with the Chief Medical Officer (CMO)/Medical Director to review PA requests. The Prior Authorization RN also ensures that appropriate information sharing takes place between the PA Department and Care Management and/or other departments to facilitate proper care management activities.

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/Humana guidelines, and PA Department policies and 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 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.

Reviews and monitors daily inpatient and subacute 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.

Conducts presentations to outside agencies and/or organizations directly or in collaboration with other Humana/iCare Departments or staff.

Assists with program and policy and procedure development for the PA Department.

Leads or participates in special projects.

Required Qualifications

Licensed Registered Nurse (RN) in Wisconsin, including compact license

Two (2) or more years of clinical acute care experience

Proficiency with Microsoft Office applications, specifically Word, Excel and Outlook

To ensure Home or Hybrid Home/Office associates' ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office associates must meet the following criteria:

At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is recommended; wireless, wired cable or DSL connection is suggested.

Satellite, cellular and microwave connection can be used only if approved by leadership.

Associates 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 associates 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.

Preferred Qualifications

Bachelor of Science in Nursing

Experience with case management, discharge planning or prior authorization

Knowledge of Milliman or Interqual

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 Work Days/Hours: Monday through Friday; 8:30am - 5:00 pm (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!

COVID-19 Vaccine Information: Humana and its subsidiaries require vaccinated associates who work outside of their home to submit proof of vaccination, including COVID-19 boosters. Associates who remain unvaccinated must either undergo weekly negative COVID testing OR wear a mask at all times while in a Humana facility or while working in the field.

Interview Format

As part of our hiring process, we will be using an exciting interviewing technology provided by Modern Hire, a third-party vendor. This technology provides our team of recruiters and hiring managers an enhanced method for decision-making.

If you are selected to move forward from your application prescreen, you will receive correspondence inviting you to participate in a pre-recorded Voice Interview and/or an SMS Text Messaging interview. If participating in a pre-recorded interview, you will respond to a set of interview questions via your phone. You should anticipate this interview to take approximately 10-15 minutes.

If participating in a SMS Text interview, you will be asked a series of questions to which you will be using your cell phone or computer to answer the questions provided. Expect this type of interview to last anywhere from 5-10 minutes. Your recorded interview(s) via text and/or pre-recorded voice will be reviewed and you will subsequently be informed if you will be moving forward to next round of interviews.

Social Security Alert

Humana Values personal identity protection. Please be aware that applicants selected for leader review may be asked to provider a social security number, if it is not already on file. When required, an email will be sent from Humana@myworkday.com with instructions to add the information into the application at Humana's secure website.

Scheduled Weekly Hours

40

Humana complies with all applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, sexual orientation, gender identity or religion. We also provide free language interpreter services. See our https://www.humana.com/legal/accessibility-resources?source=Humana_Website.

Company info

Humana Inc.
Website : http://www.humana.com