Key Responsibilities:
Responsible for taking inbound calls and assisting providers in determining whether a specific service for a member requires prior authorization or referral, ensuring compliance with established guidelines and processes.
Initiate the authorization process by collecting clinical information and verifying medical necessity, ensuring members are not subjected to unnecessary services or expenses.
Responds to provider inquiries regarding existing authorizations or referrals, and provides timely updates as needed through fax or inbound phone line, ensuring compliance with organizational policies and applicable federal regulations.
Document all call information according to standard operating procedures and attach clinical information when necessary
Support members with authorization requests, including outbound calls to provider offices when required.
Review resources and data to facilitate positive outcomes for consumers, adapting to ongoing changes in processes and procedures due to CMS regulations.
Maintain high-quality standards and meet monthly quality requirements
Ability in maneuvering multiple systems simultaneously
Work Shift can be between the hours of 6am-7pm CST, including occasional weekends
Core Competencies:
Communicate ideas and updates clearly to team members, actively listen to feedback and concerns, and facilitate open, honest dialogue.
Collaborate and contribute effectively to team projects and goals, supporting colleagues and resolving issues that impact the team.
Share knowledge, work effectively with cross-functional teams, and coordinate tasks and responsibilities among team members.
Identify and address potential conflicts within the team, facilitating constructive discussions to resolve disagreements.
**Be sure to include a resume with your application**
Required Qualifications
Minimum 1 year of customer service experience, including the ability to effectively de-escalate challenging situations
After training, you must be available to work any shift between the hours of 6am - 7pm CST and occasional weekends based on business needs
Excellent verbal and written communication skills
Demonstrated attention to detail
Ability to navigate process flows and follow procedure documents
Proficient keyboarding skills for data entry and documentation
Capacity to multitask across various computer systems while engaging with providers or members
Quick aptitude for learning and navigating new technology systems and applications
Proficiency in Microsoft Office applications, including Word and Excel
A designated workspace, with a closed door, that minimizes distractions and meets leadership approval
Must effectively manage personal responsibilities to ensure a professional work environment conducive to achieving performance goals
Preferred Qualifications
Proficient utilizing electronic medical record and documentation programs
Experience with Utilization Review and/or Prior Authorization, preferably within a managed care organization
Knowledge of Medical Terminology and/or ICD-10 codes
Experience with Utilization Review and/or Prior Authorization, preferably within a managed care organization
Bilingual (English & Spanish) fluent in written and verbal communication
Additional Information
Work-At-Home Requirements
To ensure Home or Hybrid Home/Office associates’ ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office associates must meet the following criteria:
At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is recommended; wireless, wired cable or DSL connection is suggested.
Satellite, cellular and microwave connection can be used only if approved by leadership.
Associates who live and work from Home in the state of California, Illinois, Montana, or South Dakota will be provided with a bi-weekly payment for their internet expense.
Humana will provide Home or Hybrid Home/Office associates with telephone equipment appropriate to meet the business requirements for their position/job.
Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information.
Interview Format
As part of our hiring process for this opportunity, we will be using exciting interviewing technology called HireVue to enhance our hiring and decision-making ability. HireVue allows us to quickly connect and gain valuable information for you pertaining to your relevant skills and experience at a time that is best for your schedule.
If you are selected for a first-round interview, you will receive an email correspondence inviting you to participate in a HireVue interview. In this interview, you will receive a set of interview questions over your phone, and you will provide recorded or text message responses to each question. For best interview experience use a computer over a phone. You should anticipate this interview to take about 15-20 minutes. Your recorded interview will be reviewed, and you will subsequently be informed if you will be moving forward to next round of interviews.
Humana Benefits
Humana offers a variety of benefits to promote the best health and well-being of our employees and their families. We design competitive and flexible packages to give our employees a sense of financial security—both today and in the future, including:
Health benefits effective day 1
Paid time off, holidays, volunteer time and jury duty pay
Recognition pay
401(k) retirement savings plan with employer match
Tuition assistance
Scholarships for eligible dependents
Parental and caregiver leave
Employee charity matching program
Network Resource Groups (NRGs)
Career development opportunities
Social Security Task
Humana value's personal identity protection. Please be aware that applicants may be asked to provide their Social Security Number, if it is not already on file. When required, an email will be sent from Humana@myworkday.com with instructions on how to add the information into your official application on Humana’s secure website.
Travel: While this is a remote position, occasional travel to Humana's offices for training or meetings may be required.Scheduled Weekly Hours
40Pay Range
The compensation range below reflects a good faith estimate of starting base pay for full time (40 hours per week) employment at the time of posting. The pay range may be higher or lower based on geographic location and individual pay will vary based on demonstrated job related skills, knowledge, experience, education, certifications, etc.
Description of Benefits
Humana, Inc. and its affiliated subsidiaries (collectively, “Humana”) offers competitive benefits that support whole-person well-being. Associate benefits are designed to encourage personal wellness and smart healthcare decisions for you and your family while also knowing your life extends outside of work. Among our benefits, Humana provides medical, dental and vision benefits, 401(k) retirement savings plan, time off (including paid time off, company and personal holidays, volunteer time off, paid parental and caregiver leave), short-term and long-term disability, life insurance and many other opportunities.Application Deadline: 11-05-2025
Equal Opportunity Employer
It is the policy of Humana not to discriminate against any employee or applicant for employment because of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or protected veteran status. It is also the policy of Humana to take affirmative action, in compliance with Section 503 of the Rehabilitation Act and VEVRAA, to employ and to advance in employment individuals with disability or protected veteran status, and to base all employment decisions only on valid job requirements. This policy shall apply to all employment actions, including but not limited to recruitment, hiring, upgrading, promotion, transfer, demotion, layoff, recall, termination, rates of pay or other forms of compensation and selection for training, including apprenticeship, at all levels of employment.