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The Prior Authorization Nurse, National Medicaid Clinical Operations is responsible for reviewing and evaluating clinical documentation related to prior authorization requests for outpatient services. This role ensures that all requests meet medical necessity criteria and comply with health plan policies and regulatory requirements. The Prior Authorization Review Nurse works closely with healthcare providers, interdisciplinary teams, and nonclinical staff to facilitate timely and appropriate care for members. This role operates autonomously within their scope of practice, making independent clinical decisions.
Key Responsibilities:
Clinical Review:
· Conduct comprehensive clinical reviews of prior authorization requests to determine medical necessity and benefit eligibility
· Apply advanced evidence-based clinical guidelines in review decisions
· Ensure compliance with accreditation, state, and federal regulations
Communication and Coordination:
· Communicate with healthcare providers to obtain necessary clinical information and clarify requests
· Coordinate with medical directors and interdisciplinary teams to support decision-making
· Serve as a liaison between clinicians, internal departments, and members
Documentation and Reporting:
· Document all review findings and decisions in clinical documentation systems
· Ensure timely and accurate documentation of prior authorization determinations
· Support reporting initiatives and provide data for performance improvement projects
Quality Assurance:
· Implement quality assurance measures to ensure accuracy and consistency in prior authorization decisions.
· Conduct regular audits and reviews to maintain high standards of service
· Identify process improvement opportunities and contribute to performance improvement projects.
Education and Training:
· Educate providers and staff on prior authorization policies, criteria, and review processes.
· Provide mentorship and feedback to nonclinical staff and peers to enhance workflow efficiency.
· Stay current with clinical best practices and regulatory changes
We are seeking a typical Monday-Friday schedule as well as weekend coverage (i.e. Wed-Sun, Thu-Mon or Fri-Tue type schedule). This will be discussed during interview.
Use your skills to make an impact
Required Qualifications
- Licensed Registered Nurse (RN) in Illinois, with no disciplinary action (or willing to obtain Illinois licensure upon hire)
- 3+ years of clinical nursing experience.
- Experience with Medicaid policies and procedures.
- Proficiency in healthcare software and electronic medical records (EMR) systems.
- Previous experience in utilization management
- Comprehensive knowledge of Microsoft Word, Outlook and Excel
Preferred Qualifications
- Bachelor’s degree
- Certification in Case Management (CCM) or Utilization Review (UR).
- Experience with Medicaid and Medicare policies and procedures
- Knowledge of payer policies, insurance companies and government health programs.
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.
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, paid parental and caregiver leave), short-term and long-term disability, life insurance and many other opportunities.
About us
About Humana: Humana Inc. (NYSE: HUM) is a leading U.S. healthcare company. Through our Humana insurance services and our 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 and Medicaid, families, individuals, military service personnel, and communities at large. Learn more about what we offer at Humana.com and at CenterWell.com.
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.
Additional Information
Company: Humana
Location: Illinois, Oklahoma, Ohio, Louisiana, Kentucky, Virginia, Florida, South Carolina
Salary: $71,100 - $97,800 per year
Job ID: R-423741
Specialties: Electronic Medical Record, Case Manager, Utilization Review, Utilization Management, Clinical Nurse, Prior Authorization, Outpatient
Required Licenses: RN
Experience Level: 3-5 years
