Job Description

Job Responsibilities:

• Review complex clinical criteria-based prior authorizations (electronically and/or in written format) in accordance with policies and procedures and per the health plan/employer agreed criteria.
• Refer prior authorization cases not meeting clinical criteria for upper-level review when appropriate.
• 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 ensure the operational unit is complying with regulatory requirements and accreditation standards.
• Participates in quality assurance activities on ongoing basis, 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.
• 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 programs on multiple computer screens, and keyboarding.
• Must have regular and predictable attendance.
• Colleague will be required to work overtime/work weekends when business requires.

Skills:

• Hold and maintain an active, unencumbered LPN/LVN license in the state of practice.
• Position requires proficiency with computer skills which include multitasking, navigating multiple systems, and keyboarding. Experience using MS Office, other Windows-based computer applications, web-based processing and telephony programs.
• Minimum 2 years’ recent experience reviewing and processing prior authorizations against health plan criteria for a determination in a specialty/skilled clinical setting i.e., specialty medical office or Pharmacy Benefits Manager (PBM).

Education/Experience:

• The Licensed Practical Nurse is a graduate of a school of Practical 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 must have a full, active, and unrestricted license as a Licensed Practical in a State, Territory or Commonwealth of the United States or District of Columbia.

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