Summary:
The Licensed Practical Nurse (LPN)/Licensed Vocational Nurse (LVN) will provide processing and communication of Commercial Prior Authorizations (PA) reviewed by the Commercial PA team for Pharmacy benefits. This is a high production role with required metrics.

Position Summary:
The Licensed Practical Nurse (LPN) will provide processing and communication of Commercial Prior Authorizations (PA) reviewed by the Commercial PA 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 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 criteria-based prior authorizations following policy and procedure
Provide internal nurse support to the PA 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.
You will work with pharmacists, other clinical colleagues, healthcare professionals and members.
Follow all prior authorization procedures to guarantee an accurate process on each prior authorization.
Complete other PA assignments as delegated by the PA 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
Performs and handles inbound and outbound phone calls with technicians, prior authorization team members, physicians, healthcare providers, and/or patients to facilitate prior authorization requests, answer inquiries, and/or resolve calls with a one call solution.
Performs other related projects and duties as assigned, including attending training sessions and development meetings.

Experience:

Minimum 2 years clinical experience as a LPN/LVN.
A LVN (Licensed Vocational Nurse) or LPN (Licensed Practical Nurse) that must hold an unrestricted license in their state of residence or a compact license.
Prior authorization experience or Case Management experience
3+ years prior related clinical work experience
Ability to prioritize, quickly assess, manage multiple tasks and adapt to constantly changing situations.
Experience using MS Office and other Windows-based computer applications and phone use.
Digital charting
Managed care or health plan previous experience,
Call center experience
Multi-tasking experience
Prior remote experience preferred
Case Management experience
Prior authorization experience
High production experience
Excellent organizational skills. Strong detail orientation.

Required Depth:

At least 1-3 years recent Prior Authorization experience.
Experience working within payer, health plan, PBM, utilization management, or managed care environments.
Experience handling production metrics. Simultaneous phone, documentation, and authorization processing.

Pharmacy benefit PA preferred.

Top 3 Skills:
Skill #1: Prior Authorization Experience
Skill #2: Managed Care / Health Plan Experience
Skill #3: High-Volume Remote Clinical Operations

Notes:

This position is a 100% remote, work from home in the USA opportunity and will not be patient facing.

- Work Hours:
Candidates must be able and willing to work Central Time hours, regardless of where they reside in the U.S.

Work hours vary from 8AM to 8PM CST. Training hours 8AM - 430PM CT. Mandatory OT.
Fully remote (never coming onsite)