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: