Prior Authorization Registered Nurse (Remote)

About the role

Humana is seeking a Prior Authorization Registered Nurse to join its Wisconsin Medicaid Market (iCare) team. Working remotely from home, you will evaluate the clinical appropriateness of prior‑authorization requests and ensure compliance with Medicare, Medicaid, and internal guidelines.

Key responsibilities

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

Required profile

• Active Registered Nurse license in Wisconsin (including compact license).
• Minimum two years of clinical care experience.
• Ability to work 8:30 am – 5:00 pm Central Standard Time.
• Residence within Central or Eastern Standard Time zones.

Required skills

• Knowledge of Milliman (MCG) software.
• Knowledge of TruCare system.
• Experience in Managed Care utilization management.

What we offer

• Remote work environment with occasional use of Humana office space.
• Dedicated telephone equipment and internet stipend for eligible states.
• Opportunities for professional development within a large health‑care organization.