Behavioral Health Prior Authorization Nurse

Job description

We appreciate that you are interested in pursuing your next career opportunity. As you complete the application below, here are a few tips you should consider: • Visit Go/Develop for information on professional development, resume guidance, and interview best practices.​ • Watch a quick video to discover how Humana’s Career Framework can help you identify meaningful growth opportunities. • Visit Go/AskARecruiter for expert advice on your job search from our Talent Acquisition Team. • Tailor your resume to highlight achievements and skills that align with the role you're applying for. • Update your Workday profile to reflect your key accomplishments and experiences. • Please read the job description carefully and ensure you meet all required qualifications. • Consider having a conversation with your current leader about your career goals and interest in this opportunity. Their support can be valuable as you explore your next step. Job Profile Pre-Authorization Nurse 2 Job Level Professional 2 Become a part of our caring community Humana is seeking a Behavioral Health Prior Authorization Nurse to join the Wisconsin Medicaid Market (iCare) team. You will review the clinical appropriateness of prior authorization (PA) requests. You will ensure that all benefits authorized meet medical necessity and other Medicare and Medicaid criteria 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 authorization requests for inpatient behavioral health care pursuant to applicable Medicare and Medicaid criteria, Humana/iCare 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 completion of all workflows within the Department. Use your skills to make an impact ​

Responsibilities

Requirements

• • Unrestricted license as a Registered Nurse in the state of Wisconsin or compact state. • One (1) year of experience in Utilization Management • Two (2) years of experience in mental health and/or substance abuse rehabilitation. • Available to work 8:30am-5pm in Central Standard Time (CST). • Proficient with MS Office products including Word, Excel and Outlook. • Previous experience in case management, discharge planning and/or home health or rehab. • Experience working with MCG or InterQual guidelines. • Health Plan experience working with large carriers. • Previous Medicare/Medicaid 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 – Friday, 8:30am – 5:00 pm Central Standard Time (CST) Work at Home Requirements: 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. In certain roles, the minimum recommended internet speed required by Humana may not be sufficient for business needs. Humana reserves the right to require associates to upgrade their internet service if necessary. Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information. Travel: While this is a remote position, occasional travel to Humana's offices for training or meetings may be required. Scheduled Weekly Hours 40 Pay 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. $71,100 - $97,800 per year This job is eligible for a bonus incentive plan. This incentive opportunity is based upon company and/or individual performance. Referral Bonus Information This requisition is not eligible for a referral bonus.

About Humana

Humana's Primary Care Organization operates 340+ senior-focused primary care centers across 15 states under the CenterWell and Conviva brands, providing value-based care to adult and geriatric patients. They hire Nurse Practitioners for part-time roles in collaborative, team-based primary care settings with lower patient volumes, and they hire bilingual Registered Nurses for remote telephonic care management positions supporting members with chronic and complex health conditions, requiring assessment, care planning, and coordination with interdisciplinary teams.