Humana · 1 day ago
Prior Authorization RN
Work at Home - Ohio
Full-time
Hybrid
Entry, Mid Level
$71K/yr - $98K/yr
2+ years expHumana is seeking a Prior Authorization RN to join the Wisconsin Medicaid Market (iCare) team. This position reviews the clinical appropriateness of prior authorization requests and ensures that all benefits authorized meet medical necessity and other Medicare and/or Medicaid criteria.
Health CareHealth InsuranceInsuranceVenture Capital
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
Qualification
Required
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
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
Benefits
401k
Medical
Dental
Vision
Tuition assistance
Paid time off
Company and personal holidays
Volunteer time off
Paid parental and caregiver leave
Short-term and long-term disability
Life insurance
Company
Humana
Humana is a health insurance provider for individuals, families, and businesses.
10001+ employees
H1B Sponsorship
Humana has a track record of offering H1B sponsorships. Please note that this does not
guarantee sponsorship for this specific role. Below presents additional info for your
reference. (Data Powered by US Department of Labor)
Distribution of Different Job Fields Receiving Sponsorship
Represents job field similar to this job
Trends of Total Sponsorships
2025 (282)
2024 (246)
2023 (284)
2022 (274)
2021 (212)
2020 (84)
Funding
Current Stage
Public CompanyTotal Funding
$13.07B2025-05-30Post Ipo Debt· $5B
2025-03-03Post Ipo Debt· $1.25B
2024-03-11Post Ipo Debt· $2.25B
Leadership Team
Jim Rechtin
CEO and President
Colin Drylie
Senior Vice President, Experience Transformation
Recent News
2026-01-13
2026-01-09
2026-01-07
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