LPN – Utilization Management

This is a fully remote position, open to applicants in Texas.

📋 Description

• Evaluate criteria-based prior authorizations in accordance with established policies and procedures.

• Offer on-call after-hours nursing support for urgent prior authorization requests.

• Provide internal nursing assistance to the PA team and the member services department.

• Refer cases that do not satisfy clinical criteria to the Pharmacist and MD teams.

• Relay prior authorization status to physician office staff and coordinate with customer service, admissions, and pharmacy operations departments.

• Process fax requests and deliver telephone support to prescriber office personnel, pharmacies, and members.

• Respond to inbound phone inquiries.

• Process cases and input authorizations into the system.

• Conduct follow-up phone calls as needed.

• Maintain comprehensive and precise documentation through data entry, management, and reporting in the computer system.

• Collaborate with pharmacists, clinical colleagues, healthcare professionals, and members.

• Train and mentor representatives within the PA team.

• Complete additional prior authorization tasks assigned by PA leadership.

⛳️ Requirements

• Previous experience with prior authorizations in Novologix.

• Exceptional interpersonal skills.

• Proven problem-solving skills and attention to detail.

• Ability to work efficiently within a team environment with strong reliability.

• Outstanding oral and written communication skills.

• Capability to quickly evaluate and adapt to rapidly changing situations.

• Proficient in phone and PC usage.

• High level of mental agility and alertness.

• Skill in effectively communicating with pharmacists, clinical colleagues, healthcare professionals, and members.

• Ability to prioritize tasks effectively with a sense of urgency.

• Capacity to accurately and promptly follow prior authorization procedures.

• Competence in training and mentoring representatives on the PA team.

• Active LPN license in the state of practice is required.

• Associate’s or Bachelor’s Degree in Nursing is preferred.

• Willingness to work 40 hours per week.

🏝️ Benefits

• Medical coverage.

• Dental coverage.

• Vision coverage.

• Paid time off.

• Retirement savings options.

• Wellness programs.

• Additional resources supporting physical, emotional, and financial well-being.

• CVS Health bonus, commission, or short-term incentive program in addition to base pay.