Prior Authorization RN (Remote)

About the role

Humana is seeking a Prior Authorization RN to join its Wisconsin Medicaid Market (iCare) team. Working remotely, you will evaluate the clinical appropriateness of prior‑authorization requests, ensuring they meet Medicare, Medicaid, and internal guidelines while supporting cost‑effective care.

Key responsibilities

• Review outpatient prior‑authorization requests against Medicare, Medicaid, iCare, and department procedures.
• Document rationale for approvals or forward cases to the CMO/Medical Director for further review.
• Prepare reduction or denial letters based on clinical guidelines and leadership feedback.
• Stay current on Medicare and Medicaid policy changes.
• Collaborate with PA staff to complete departmental workflows.
• Assist in developing programs and procedures for the PA department.
• Lead or contribute to special projects as needed.

Required profile

• Active Registered Nurse license in Wisconsin (including compact license).
• Minimum two years of clinical care experience.
• Availability to work 8:30 am–5:00 pm Central Standard Time.
• Preferred: Bachelor of Science in Nursing, one year of utilization management experience, residence in CST or EST time zones, knowledge of Milliman (MCG) and TruCare, managed‑care experience.

Required skills

• Knowledge of Medicare and Medicaid guidelines.
• Familiarity with iCare guidelines and PA department procedures.
• Experience with Milliman (MCG) software.
• Experience with TruCare system.

What we offer

• Remote work environment with occasional use of Humana office space.
• Dedicated home workspace meeting PHI/HIPAA standards.
• Internet stipend for eligible states.
• Company‑provided telephone equipment.