Job Description:
ESSENTIAL JOB FUNCTIONS
- Reviews cases and applies medical criteria to evaluate and submit authorizations to MCO’s, Medicare and commercial insurance companies based on medical necessity.
- Collaborates with site providers and nurses, pharmacies and insurance to advocate and meet the needs of the client.
- Interprets and communicates medication denials with site providers offering guidance and education.
- Communicates with site providers and nurses to provide ongoing education around medication formulary requirements.
- Conducts chart audits for medical necessity, quality and compliance standards.
- Reviews UM reports for outstanding and expiring authorizations to be completed.
- Documents and maintains accurate records of all communications.
- Maintains a centralized knowledge base around formularies and prior authorization requirements.
- Provides date and trends to medical leadership around medication denials and approvals.
The intent of this job description is to provide a representative summary of the major duties and responsibilities performed by incumbents of this job. Incumbents may be requested to perform job-related tasks other than those specifically presented in this description.
EDUCATION
- Completion of certified nursing program
EXPERIENCE
- Five plus years of clinical experience.
- At least one year of utilization case management preferred.
REQUIREMENTS
- Kentucky Board of Nursing active and unencumbered LPN or RN license
PHYSICAL DEMANDS
- Occasional minor discomforts from continual exposure to video display terminal
Within the bounds of their respective job descriptions, all staff are expected to exercise principle-centered leadership, focused on customer service responsiveness, with a continuous quality improvement orientation. Additionally, all staff are expected to develop a working knowledge of and follow all policies and procedures related to safety management and other Joint Commission standards.
Time Type:
Full time
