Nurse Associate LPN

Nurse Associate LPN

  Not Disclosed

  Woonsocket, RI (100% Remote)

  6.0 Months

  Not Disclosed

  Not Disclosed

  Pharmaceutical

  $20.98/hour - $25.98/hour

Job Description

Description:

Position Summary:

• The Nurse Associate LPN - Prior Authorization is responsible for the efficient, accurate and timely prioritization and management of work.
• Provides support to the Prior Authorization Department in meeting client expectations regarding efficiency, service levels, privacy maintenance and quality of decision-making.
• Responsible for maintaining compliance with ERISA, CMS, and client specific requirements. Works as part of the team to meet business unit objectives.
• This position is also responsible for receiving calls from physician offices and providing professional and courteous assistance to all callers through the criteria-based process.
• The Nurse Associate LPN will follow criteria question set prompts to facilitate system-generated approvals.
• Further responsibilities include maintaining complete, timely, and accurate documentation of all requests, communicating to the physician’s office, pharmacies, intake etc. as needed, and transfers all clinical questions and judgement calls to the Clinical Pharmacist as needed.
• The Nurse Associate LPN will also assist with other duties such as outbound calls, monitoring/responding to inquiries in mailboxes and other duties as assigned by the leadership team.
• The Nurse Associate LPN will support requirements of the PA team by working as part of a weekend coverage team on a rotating basis where needed.

• You will provide processing and communication of specialty medication prior authorization (PA) requests reviewed by the client Specialty Medical Prior Authorization department. Reporting to the Pharmacy Operations Manager, you will work with physician office staff and customer service, admissions and pharmacy operations departments to communicate prior authorization status. You will also oversee fax processing and provide telephone call assistance for prescriber office staff, pharmacies and members based on program criteria.

• Responsibilities include answering inbound phone calls, processing cases and electronic authorizations, loading authorizations, and making follow-up phone calls utilizing appropriate courteous and professional behavior based upon established standards. Maintaining complete and accurate, documentation of all necessary information is necessary and will involve computer system data entry, data management, and reporting.

• Review criteria-based prior authorizations following policy and procedure.
• Provide on-call after hours nurse availability for urgent PA requests.
• 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.
• Excellent verbal and written skills.
• 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.
• Train and mentor representatives on the PA team.
• Complete other PA assignments as delegated by the PA leadership team.

Duties:

• 1.Effectively manage work volume by handling inbound calls/fax requests utilizing appropriate courteous and professional behavior based upon established standards. Sort incoming faxes in compliance with departmental and client requirements.
• 2.Manage case load for all clients by researching and triaging incoming fax requests. Use eligibility systems to identify the type of request and create, route, and/or complete appeals or requests in accordance with department processes. Process External Review appeal requests according to federal, client, and state mandated guidelines.
• 3.Act as a subject matter expert and assists with Coordinator duties dependent upon business needs. Provides support/mentoring to Coordinator staff to solve case processing questions and issues.
• 4.Collaborate with Pharmacy Technicians, Pharmacists, and other internal partners for timely resolution of issues with case processing.
• 5.Works closely with internal partners to develop work instructions and promote process improvements.
• 6.Other duties assigned.

Experience:

• 1-3 years experience
• Ability to deal with a diverse customer base in a friendly and confident manner (internal and external customers).
• Proficient with computer systems and Microsoft Office skills, including Access, Excel and Word.
• Ability to navigate systems in Windows and web-based programs, and quickly learn new applications.
• Ability to prioritize and manage multiple tasks.
• Demonstrated sense of urgency with assignments.
• Excellent organization skills. Strong detail orientation.
• Demonstrated problem-solving ability.
• Strong verbal and written communication skills.
• Ability to maintain confidentiality.
• Knowledge of claim eligibility processes.
• Works well as a member of a team with strong interpersonal skills.
• Seeks ways to collaborate and reach consensus with peers.
• Actively works to build strong working relationships.
• Able to customize messages and deliver to broader audiences.
• Background in creating and maintaining reports is a plus.

Education:

• Associate’s (REQUIRED) or Bachelor’s Degree: Nursing preferred
• Other Certificates or Licenses (List): Active LPN license in the state of practice required
• 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 US or District of CA.
• RNs will be considered as well

Note:

This is a remote position and requires the ability to effectively support a work from home environment

8 hour shift Monday to Friday anywhere between 8:00 am to 12:00 am CST; possible weekends

Training schedule is approximately three weeks starting 03/31/2025, Monday to Friday 8:00am - 4:30pm CST, then schedule will be assigned: Expected shifts to be 8 hours per day, Must be ok working Monday through Friday with the shifts being anytime between the hours of 8am CST and 12AM CST, with potential weekend requirements. The work schedule will be determined after training is completed; the CW will not have a choice of shift.