Prior Authorization RN – Remote (Wisconsin Medicaid)

About the role

Humana is seeking a Registered Nurse to join its Wisconsin Medicaid (iCare) Prior Authorization team. Working remotely from home, you will evaluate outpatient prior‑authorization requests to ensure they meet Medicare, Medicaid and internal criteria, supporting cost‑effective care delivery.

Key responsibilities

• Review prior‑authorization requests for outpatient services against Medicare, Medicaid, iCare guidelines and department procedures.
• Document clinical rationale for approvals or forward cases to the CMO/Medical Director for further review.
• Prepare reduction or denial letters in line with reviewer recommendations and applicable guidelines.
• Stay current on Medicare and Medicaid policy changes and apply them to daily work.
• Collaborate with PA staff to complete workflow tasks and assist in developing department procedures.
• Lead or contribute to special projects and program development initiatives.

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, Monday‑Friday.
• Residency in the Central or Eastern Standard Time zones.

Required skills

• Knowledge of Milliman (MCG) software.
• Familiarity with TruCare system.
• Experience in managed‑care or utilization management environments.

What we offer

• Fully remote work with occasional use of Humana office space for collaboration.
• Dedicated home workspace with required internet speed (≥25 Mbps download, ≥10 Mbps upload).
• Company‑provided telephone equipment and bi‑weekly internet stipend for eligible states.
• Opportunities for professional development within a supportive healthcare community.