The Licensed Practical Nurse (LPN) or Licensed Vocational Nurse (LVN) will provide processing and communication of Commercial Prior Authorizations (PA) and Appeals reviewed by the Commercial PA and Appeals team for Pharmacy 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 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.

Position Summary
We are seeking experienced LPN/LVN candidates with prior authorization experience in a specialty medical office (MDO), PBM, or clinical setting. This role requires the ability to work in a?high-volume, metrics-driven environment?while maintaining strong clinical judgment, accuracy, and efficiency.
Successful candidates are?self-directed, resourceful, and adaptable, with the ability to quickly interpret clinical information, navigate multiple systems simultaneously, and maintain productivity while managing competing priorities. This is a fully remote role requiring?a high level of accountability, focus, and independence throughout the entire shift.

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.
Excellent verbal and written skills.
You will work with pharmacists, other clinical colleagues, healthcare professionals and members.
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
Ability to multitask, prioritize, and effectively adapt to a fast paced changing environment
This position involves sedentary work with periods of sitting, talking, listening. Work requires sitting for extended periods, talking on the telephone, and typing on the computer.
Position requires proficiency with computer skills which include navigating multiple systems and keyboarding
Excellent communication skills, both written and verbal
Must have regular and predictable attendance

Duties
Manage inbound and outbound calls while maintaining?productivity, quality, and service level expectations
Review and process complex prior authorization and appeals requests using clinical criteria and supporting documentation
Navigate?multiple systems, tools, and communication platforms simultaneously?with speed and accuracy
Review chart notes, claims history, and prior authorization history to make accurate determinations
Submit complete and accurate documentation to support determinations and avoid unnecessary delays
Identify cases requiring escalation and refer appropriately
Demonstrate?critical thinking and problem-solving when information is unclear or incomplete
Apply internal workflows, job aids, and policies correctly and consistently
Adapt quickly to?changing priorities, processes, and clinical criteria
Communicate clearly and professionally with team members, pharmacists, providers, and leadership
Ask questions and seek clarification when needed to ensure accuracy
Maintain?attention to detail while processing high volumes of work efficiently
Participate in quality assurance activities and apply feedback for continuous improvement
Perform work in a?sedentary, desk-based environment?requiring prolonged sitting, typing, and screen time
Maintain consistent attendance, productivity, and adherence to scheduled work hours

Experience
Active, unrestricted LPN/LVN license
Minimum?2+ years of recent prior authorization experience?in a PBM, MDO, or clinical setting
Experience reviewing and applying clinical criteria and supporting documentation for PAs
Experience using CoverMyMeds or similar authorization platforms
Familiarity with chart notes, claims history, and insurance requirements
Licensed as an LPN in the state in which they reside.

Top Skills:
Active unrestricted LPN/LVN license
Minimum 6 months[s] [/s]prior authorization experience
Prior appeals experience is preferred
PBM, specialty pharmacy, payer, or medical office (MDO) experience

Education
Graduate of an accredited school of Practical Nursing (NLNAC or equivalent)
Must maintain active licensure in good standing

Notes:
Fully remote
Training-M-F 8am-4:30pm CT/permanent schedule: Shifts M-F between 8:00am-7:00pm CT.