[Hiring] UM Medication Prior Authorization Nurse @Seven Counties Services

Role Description

• 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 data and trends to medical leadership around medication denials and approvals.

Qualifications

• Completion of certified nursing program.
• 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.

Company Description