Behavioral Health Prior Authorization Nurse

Humana

. Review authorization requests for inpatient behavioral health care pursuant to applicable Medicare and Medicaid criteria, Humana/iCare guidelines, and PA Department policies and procedures .

Posted 10/12/2026full-timeRemote • Wisconsin • United StatesJuniorMid-Level💰 $71,100 - $97,800 per yearWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in Utilization Management and mental health rehabilitation, with a strong understanding of Medicare and Medicaid guidelines. Proficient in case management and documentation practices to ensure compliance and effective communication with healthcare teams.

Highest-signal resume keywords

Registered Nurse LicenseUtilization Management ExperienceMental Health Rehabilitation ExperienceMCG or InterQual Guidelines ExperienceMedicare/Medicaid Experience

ATS Keywords

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Applicant Tracking System Keywords

Tip: use these terms in your resume and cover letter to boost ATS matches.

Hard Skills

Utilization ManagementCase ManagementDischarge PlanningDocumentation PracticesMental Health RehabilitationSubstance Abuse Rehabilitation

Soft Skills

CollaborationAttention to DetailCommunication

Tools & Technologies

MS OfficeWordExcelOutlook

Certifications & Qualifications

Registered Nurse License

Industry Keywords

Medicare GuidelinesMedicaid GuidelinesHealth Plan ExperiencePHI/HIPAA Compliance

About the role

Key responsibilities & impact

Review authorization requests for inpatient behavioral health care pursuant to applicable Medicare and Medicaid criteria, Humana/iCare guidelines, and PA Department policies and procedures
Provide complete and accurate documentation specifying rationale for approval or forwarding to the CMO/Medical Director for further review
Create reduction/denial letters based on the CMO/Medical Director's review and applicable guidelines
Maintain a thorough understanding of Medicare and Medicaid guidelines and stay abreast of updates and changes
Collaborate with PA staff to ensure timely completion of all workflows within the Department

Requirements

What you’ll need

Unrestricted license as a Registered Nurse in the state of Wisconsin or compact state
One (1) year of experience in Utilization Management
Two (2) years of experience in mental health and/or substance abuse rehabilitation
Available to work 8:30am-5pm in Central Standard Time (CST)
Proficient with MS Office products including Word, Excel and Outlook
Previous experience in case management, discharge planning and/or home health or rehab (preferred)
Experience working with MCG or InterQual guidelines (preferred)
Health Plan experience working with large carriers (preferred)
Previous Medicare/Medicaid experience (preferred)
Minimum download speed of 25 Mbps and upload speed of 10 Mbps
Ability to work from a dedicated space without ongoing interruptions to protect member PHI/HIPAA information

Benefits

Comp & perks

Bonus incentive plan based upon company and/or individual performance
Medical benefits
Dental benefits
Vision benefits
401(k) retirement savings plan
Paid time off
Company holidays
Personal holidays
Paid parental leave
Paid caregiver leave
Short-term disability
Long-term disability
Life insurance
Work-from-home arrangement
Training and meeting opportunities