Prior Authorization Nurse, Rn - Folcroft, United States - Chemistry Rx

Description

SUPERVISED BY
Clinical Nurse Manager


JOB RESPONSIBILITIES
Nurse performs various duties related to the prior authorization of prescription orders and specialty medical utilization management.

The nurse will work closely with prescribers, patients, and their families to develop sound and well-supported arguments that reflect the medical necessity of the prescription order.

The nurse will also stay abreast of updates to treatment guidelines and of clinical publications that may impact the treatment landscape of various diseases, with a particular focus on rare disorders.

The nurse will also be communicating with prescribers, patients and their families regarding prescription orders, the customization of compounded medications, and she/he will conduct extensive phone interviews with patients.

JOB DUTIES

• Communicates with thirdparty payers and providers regarding initial and concurrent clinical review.
• Helps to support the appeal process to overturn insurance denials and/or benefit exclusions.
• Enters authorizations into the appropriate system to ensure accurate claims processing.
• Interacts with providers to gain additional clinical information regarding their prescription order.
• Creates patient care plans and provides followup assessment.
• Handles outbound and inbound calls to/from patients, office staff and prescribers.
• Provides clinical support to medicationrelated questions.
• Assists with the establishment of clinical standards/processes.
• Ensures close coordination with pharmacists on patient clinical management.
• Always represents the company in a professional manner and appearance.
• Adheres to all company policies as indicated in the handbook and directives issued by management.

COMPETENCIES

• Verbal and Written communication skills
• Quality Focus
• Attention to Detail
• Accountability
• Compliance
• Productivity

WORK ENVIRONMENT
This job operates in a Pharmacy and remotely. This role routinely uses standard office equipment such as computers, phones, photocopiers, filing cabinets and fax machines.


PHYSICAL DEMANDS

• The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job.
• While performing the duties of this job, the employee is regularly required to talk or hear.
• The employee frequently is required to stand; walk; use hands to finger, handle or feel; and reach with hands and arms.

REQUIRED EDUCATION AND EXPERIENCE

• Registered Nurse from an approved program by the National League of Nursing Accrediting Commission or the Commission on Collegiate Nursing Education
• Licensure valid for the pharmacy's home state and the employees home state if working remotely
• Proven experience as a nurse in a clinical setting
• Knowledge of medication and dosage measurement
• Knowledge of medical terminology
• Excellent communication and customer service skills
• Outstanding organizational skills
• Reliable with a keen eye for detail

PREFERRED EDUCATION AND EXPERIENCE

• Completion of a Registered Nursing (associate degree or bachelor's degree) program approved by the Commission on Collegiate Nursing Education (CCNE) or National League of Nursing Accrediting Commission (NLNAC).
• At least 23 years of nursing experience.

AAP/EEO STATEMENT

The pharmacy provides equal employment opportunity to all individuals regardless of their race, color, creed, religion, gender, age, sexual orientation, national origin, disability, veteran status, or any other characteristic protected by state, federal, or local law.

Benefits:

• 401(k)
• 401(k)

matching

• Dental insurance
• Flexible spending account
• Health insurance
• Health savings account
• Life insurance
• Paid time off
• Vision insurance

Standard shift:

• Day shift

Weekly schedule:

• Monday to Friday

Experience:

Prior Authorization: 2 years (required)


License/Certification:

• Pennslyvania Nursing License (required)

Work Location:
Hybrid remote in Folcroft, PA 19032