(LPN/LVN) Appeals Nurse/Utilization Review/ Pri...

Get AI-powered advice on this job and more exclusive features. Licensed Vocational Nurse/Licensed Practical Nurse - Prior Authorization Position type : Full time Location: Fully remote Onsite Flexibility: All Remote Pay range : ($25.00 - $28.50) Job Description: Training schedule is approximately 5-7 weeks, Monday to Friday 8:00am - 4:30pm CST, then schedule will be assigned: Expected shifts to be 8 hours per day, which will include one weekend day per week. Provide processing and communication of Specialty medication prior authorization (PA) referrals reviewed by the Case Review Unit (CRU) for the Specialty Guideline Management Programs for the Pharmacy and Medical benefits. Reporting to the Pharmacy Operations Manager, 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 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. Duties: • Review complex clinical criteria-based prior authorizations in accordance with client policies and procedures. • Refer prior authorization cases not meeting clinical criteria for upper-level review when appropriate. • Must possess excellent communication skills, both written and verbal. • Shift priorities while exhibiting a high level of urgency and responsiveness with all calls, prior authorization requests, and ADHOC assignments. • Follow all prior authorization procedures to meet business quality standards and ensuring the operational unit is complying with regulatory requirements and accreditation standards. • Participates in quality assurance activities on ongoing bases, including but not limited to reviewing work instructions and job aids regularly. • Collaborate with representatives on the prior authorization team, pharmacists, clinical colleagues, healthcare professionals, clients, leaders, and team members. • Complete other prior authorization assignments as delegated by the leadership team. • Working hours will vary. Shift range includes Sunday – Saturday 8:00 AM – 6:00 PM CST. • Utilization of clinical and problem-solving skills to support the research of documentation, communication of medical services, and prior authorization determinations. • Ability to multitask, prioritize, and effectively adapt to a fast-paced changing environment. • This position involves sedentary work with extended periods of sitting, talking on the telephone, using multiple computer screens, and keyboarding. • Position requires proficiency with computer skills which include multitasking, navigating multiple systems, and keyboarding. • Must have regular and predictable attendance. • Colleague will be required to work business required overtime/work weekends when business requires, making outreach, and processing prior authorization requests. Experience: • Hold and maintain an active LPN/LVN license in the state of practice. • Minimum 1 year experience reviewing and processing prior authorizations against health plan criteria for a determination in a clinical setting i.e. medical office or Pharmacy Benefits Manager (PBM). • 1-3 years prior related work experience as an LPN/LVN in a medical office, PBM or clinical setting. • Experience using MS Office, other Windows-based computer applications, and phone use. Position Summary: This is a remote position and requires the ability to effectively support a work from home environment. Must have the ability to work in a HIPAA compliant work area away from distractions, and must have their own secure private internet services of at least 25mbps download/3mbps upload in order to ensure sufficient speed to adequately perform work duties. Must provide a screenshot of internet speeds with resume and provide license number. Education The Licensed Practical Nurse is a graduate of a school of Practical or Vocational Nursing, approved by the State Agency and/or accredited by the National League for Nursing (Accrediting Commission (NLNAC)) at the time the program was completed by the applicant. The LPN/LVN must have a full, active and unrestricted license as a Licensed Practical or Vocational Nurse in a State, Territory or Commonwealth of the United States or District of Columbia. Schedule: 8 hour shift Monday to Friday anywhere between 8:00 am to 12:00 am CST; possible weekend