Licensed Practical Nurse LPN - Prior Authorization/appeals ...

Position Overview
This remote, work-from-home opportunity does not involve direct patient interaction. You will undergo approximately three weeks of training starting on August 7, 2023, from Monday to Friday, 8:00 AM - 4:30 PM CST. Following training, your schedule will be assigned, expected to consist of 8-hour shifts between 8:00 AM and 12:00 AM CST, with potential weekend... requirements.
Responsibilities
Process and communicate specialty medication prior authorization (PA) requests reviewed by the Caremark Specialty Medical Prior Authorization department.
Report to the Pharmacy Operations Manager and collaborate with physician office staff, customer service, admissions, and pharmacy operations departments to relay PA status.
Manage fax processing and provide telephone support for prescriber office staff, pharmacies, and members based on program criteria.
Answer inbound phone calls, process cases and electronic authorizations, load authorizations, and conduct follow-up calls with courteous and professional demeanor.
Maintain thorough and accurate documentation through computer system data entry, data management, and reporting.
Review and process criteria-based prior authorizations following established policies and procedures.
Provide after-hours nurse availability for urgent PA requests and internal nurse support to the PA team and member services department.
Refer cases not meeting clinical criteria to Pharmacist and MD teams.
Demonstrate flexibility by prioritizing tasks with a sense of urgency across all calls and assignments.

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

Ensure adherence to all prior authorization procedures to maintain accuracy throughout the authorization process.

Train and mentor representatives within the PA team.

Perform additional PA-related assignments as delegated by the PA leadership team.

Requirements

HIPAA compliant work environment with no distractions.

Secure, private internet service with a minimum speed of 25 Mbps download / 3 Mbps upload.

Previous Experience With CVS/Aetna Is Not Required.

High School Diploma or GED is required.

Qualifications

1-3 years of experience in a similar role.

Proficiency in Microsoft Office suite (Word, Excel, Access).

Ability to navigate Windows and web-based applications efficiently.

Strong organizational skills with attention to detail.

Problem-solving skills and a demonstrated sense of urgency.

Excellent verbal and written communication skills.

Ability to maintain confidentiality and prioritize multiple tasks.

Familiarity with claim eligibility processes is beneficial.

Team-oriented with strong interpersonal skills.

Background in creating and maintaining reports is advantageous.

Application Note

This position requires full COVID-19 vaccination by the start date, subject to approved medical or religious exemptions.

Employment Type: Full-Time

Apply Job!