Job Level

Professional

Job Summary

The Nurse Prior Authorization is responsible for evaluating diagnoses and other clinical criteria to complete requests for prior authorization, prior authorization appeals and letters of medical necessity, as required by payer guidelines for defined drugs. The Nurse Prior Authorization will gather all relevant clinical information and supporting documentation to complete prior authorization requests, appeals for prior authorization denials for the physician to review, complete and submit to the payer. Works with providers, payers, patients and pharmacies to determine coverage status and contracted vendors for provision of service for prescribed medication. The nurse is also responsible for enhanced nursing services support and assistance with Biopharma Program Calls including Physician Welcome calls, Nursing Therapy and Nursing Enhanced Adherence calls.

Job Responsibilities

• Review prior authorization criteria for specified payers related to defined medications
• Interpret prior authorization and appeal requirements for payers, and gather all relevant clinical and supporting documentation to draft PA or Appeal to submit to physician for review, completion and submission to the payer
• Evaluate all requests for prior authorizations, appeals and accompanying tasks
• Work with and interpret all software tools that assist with prior authorization materials with providers, payers and patients to determine coverage status and contracted vendors for provision of service for prescribed medication
• Act as a liaison between physicians/practitioners, medical consultants and facility clinical staff
• Interpret and follow all Payer guidelines
• Coordinate provider requests through fax, phone and online system
• Participate in professional organizations and workshops to gain additional job-related knowledge
• Participate in corporate Quality/ Performance Improvement program as required, in-service programs and continuing education as required
• Measure performance of Prior Authorization, Appeal as it relates to completion and success

Job Responsibilities, continued

• Complete BioPharma Program call outreaches and follow-up assessments to determine medication history, medication adherence barriers
• Implement and maintain patient-focused Clinical Management Programs to improve medication adherence, provide disease state education including medication administration, resources on side effect management, outreaches to MDO, per pharma and payer requirements.
• Provide nursing support within the scope of practice for a nurse and escalating patients to a pharmacist for patient specific medication questions including side effect management, and quality of life screening.
• Other responsibilities as judgment or necessity dictate

Supervisory Responsibilities

N/A

Physical Requirements

Constantly (67-100% of time OR 6 or more hours) required to sit, use hands to handle or feel, talk and hear

Frequently (34-66% of time OR 4-6 hours) required to reach with hands and arms

Occasionally (0-33% of time OR 1-3 hours) required to stand, walk and stoop, kneel and crouch

Occasionally (0-33% of time OR 1-3 hours) required to lift and/or move up to 10 pounds and occasionally lift and/or move up to 25 pounds

Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, depth perception and ability to adjust focus

Minimum Qualifications

Associate’s Degree in Nursing

Current license / registration as an RN (Registered Nurse) without restriction, in good standing with the State Board of Nursing in the state in which the position is posted

If applicable, ability to obtain and maintain Nurse Licensing Compact multistate license and necessary non- Nursing Licensing Compact state licenses within 6 months of employment start date ( company - sponsored) when job function requires: any and all exceptions to this timeline requires leadership approval

2 years’ work experience in nursing, specialty pharmacy and or prior authorization / appeals

Additional Qualifications

Strong attention to details and quality with proven problem-solving skills

Excellent written/ verbal communication skills and interpersonal skills with the ability to lead, motivate, and communicate with internal and external customers

Knowledge of customer service principles and processing including customer needs assessment, meeting quality standards for services, and evaluation of customer satisfaction

Organized and detail oriented with proven problem solving skills

Basic skills in Microsoft Office Suite of products

Willing to travel up to 10% of the time

Preferred Qualifications

Bachelor’s degree in nursing, Healthcare or related area of study or equivalent combination of education and/or related work experience

Active Nurse License Compact in multistate licensure