Registered Nurse Prior Authorization Review

Full time @Nursetohire in Nurse
  • Post Date : November 4, 2022
  • Apply Before : November 4, 2028
  • Salary: $13.00 - $15.00 / Hourly
  • 0 Application(s)
  • View(s) 156
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Job Detail

  • Job ID 7066
  • Offered Salary 1000
  • Experience Less Than 1 Year
  • Industry Management
  • Qualifications Medical

Job Description

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

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