Provide internal nurse support to the PA/Appeals team and member services department Refer cases not meeting clinical criteria to the Pharmacist and MD team(s). Our Client, a Retail Pharmacy, is looking for a Prior Authorization Licensed Vocational Nurse (LPN/LVN) to work remotely within the United States.
Numbers & Facts
Location
RI
Description
Our Client, a Retail Pharmacy, is looking for a Prior Authorization Licensed Vocational Nurse (LPN/LVN) to work remotely within the United States.
Responsibilities:
Provide processing and communication of Commercial Prior Authorizations (PA) and Appeals reviewed by the Commercial PA and Appeals team for Pharmacy benefits.
Working with physician office staff and customer service, admissions and pharmacy operations departments to communicate referral status.
You will also oversee fax processing and providing telephone call assistance for prescriber office staff, pharmacies and members based on program criteria.
Responsibilities include answering inbound phone calls, processing cases, loading authorizations, and determinations, and making follow-up phone calls.
Maintaining complete and accurate, documentation of all necessary information is necessary and will involve computer system data entry, data management, and reporting.
Review criteria-based prior authorizations/appeals following policy and procedure
Provide internal nurse support to the PA/Appeals team and member services department Refer cases not meeting clinical criteria to the Pharmacist and MD team(s).
Shift priorities while exhibiting a high level of urgency with all calls and assignments.
Follow all prior authorization and appeals procedures to guarantee an accurate process on each prior authorization.
Train and mentor representatives on the PA/Appeals team. Complete other PA/Appeals assignments as delegated by the PA/Appeals leadership team.
Utilization of clinical skills to support the documentation and communication of medical services and prior authorization determinations