Medication Prior Authorization Nurse

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

📋 Description

• Evaluate cases and apply medical criteria to assess and submit authorizations to MCOs, Medicare, and commercial insurance companies based on medical necessity.

• Work collaboratively with site providers, nurses, pharmacies, and insurance representatives to advocate for and fulfill client needs.

• Interpret and communicate medication denials to site providers, offering guidance and educational support.

• Engage with site providers and nurses to provide ongoing education regarding medication formulary requirements.

• Perform chart audits to ensure compliance with medical necessity, quality, and regulatory standards.

• Analyze utilization management reports to track outstanding and expiring authorizations.

• Accurately document and maintain records of all communications.

• Develop and maintain a centralized knowledge base of formularies and prior authorization requirements.

• Supply medical leadership with data and trends concerning medication denials and approvals.

• Demonstrate principle-centered leadership with a focus on customer service responsiveness and continuous quality improvement.

⛳️ Requirements

• Completion of an accredited nursing program.

• Over five years of clinical experience.

• At least one year of experience in utilization case management is preferred.

• Active and unencumbered LPN or RN license from the Kentucky Board of Nursing.

• Only candidates from Greater Louisville will be considered.

• Understanding of policies and procedures related to safety management and Joint Commission standards.

• Capability to review medical criteria and assess medication prior authorizations.

• Proficiency in communicating medication denials while providing guidance and education.

• Competence in conducting chart audits for medical necessity, quality, and compliance standards.

• Ability to maintain precise records and a centralized knowledge base of formularies and prior authorization requirements.

🏝️ Benefits

• Opportunity for remote work arrangement.