Prior Authorization RN - Outpatient

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.

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

$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.