Clinical Nurse Concierge - BioPlus Specialty Pharmacy

Elevance Health•Atlanta, GA

6d•Hybrid

About The Position

BioPlus Specialty Pharmacy, a proud member of the Elevance Health family, offers unparalleled service focused on whole health through clinical expertise, digital capabilities, and broad access to specialty medications. The Clinical Nurse Concierge is responsible for coordinating the care needs of assigned patients and developing comprehensive plans to manage care delivery across the patient care continuum. This role requires associates to be in-office 1-2 days per week, fostering collaboration and connectivity, while providing flexibility for productivity and work-life balance. Alternate locations may be considered if candidates reside within a commuting distance from an office. Candidates not within a reasonable commuting distance will not be considered unless an accommodation is granted.

Requirements

Requires BA/BS in a health-related field and a minimum of 5 years of clinical experience; or any combination of education and experience which would provide an equivalent background.
Current, unrestricted RN license in applicable state(s) required.
Multi-state licensure is required if this individual is providing services in multiple states.

Nice To Haves

Prior IV therapy/infusion experience (infusion center, specialty pharmacy, or outpatient/hospital setting) preferred.
Case Management certification (e.g., CCM or equivalent) preferred.
Experience managing infusion medication prior authorizations, denials, and appeals end-to-end.
Ability to complete deep clinical chart reviews and identify the strongest clinical rationale for coverage.
Skilled in writing Letters of Medical Necessity tailored to payer criteria and patient-specific facts.
Proven success preparing and submitting 1st/2nd level appeals (standard and expedited).
Experience supporting peer-to-peer reviews with concise clinical summaries and provider talking points.
Strong working knowledge of payer policies/medical necessity criteria for infusion therapies (step therapy, site-of-care, documentation requirements).
Ability to use clinical guidelines and evidence to support approvals and overturn denials.
Detail-oriented in compiling complete, accurate documentation (records, labs, imaging, prior treatment history).
Strong collaboration skills with providers, nurses, pharmacy, and revenue cycle/PA teams to prevent treatment delays.
Track record of improving outcomes (e.g., higher approval/overturn rates, faster turnaround times, fewer repeat denials).

Responsibilities

Introduce and inform current and new immunoglobulin patients and referral sources about the services and programs offered.
Provide additional touchpoints to customers, act as a resource for outside salespeople, and help solve problems as needed.
Oversee the referral process and maintenance of EMR.
Thoroughly understand and explain organizations Infusion product offerings and key benefits to current and potential patients and physician customers.
Act as the single point of contact for patients and referral sources ensuring high levels of customer satisfaction.
Provide industry-leading customer service and advocacy for BioPlus patients and customers.
Intervene immediately when a potential bottleneck in our system may occur.
Develop and distribute consumer/patient educational materials and resources.
Communicate the story and explain competitive advantage.
Discuss insurance limits and parameters of policy with patients prior to beginning services.
Act as a liaison between home health agencies, home infusion centers, and physicians to coordinate discharge, plan for patient care, and establish Plans of Treatment.
Coordinate therapeutic monitoring pertinent to therapy with home health care agency, laboratory, and specialty infusion center pharmacy.
Coordinate pharmacy dispensing schedule with delivery of drugs and supplies.
Verify disposable supplies are packed and are appropriate for patient needs.
Coordinate with home health care agency, laboratory, and specialty pharmacy for injectable self-administration teaching, lab coordination, and shipment arrangements.
Coordinate patient care at refill, establishing current response to therapy and ADR/Adherence occurrences, forwarding all clinical calls to appropriate clinician, under the supervision of the pharmacist.
Responsible for all activities and duties including but not limited to appropriate communications via progress notes, arranging nursing, patient communications, health care professional communications, completing scheduling board, as well as scheduling shipments via patient contact and communication in computer system, e-mail system and verbally.
Coordination involvement and auditing of requirements of specific clinical programs as per policy and procedures (REMS, IgG, Hemophilia, etc.).
Participate in center QA&I to ensure achievement of excellence.
Ensure compliance with all Policies and Procedures and Pharmacy and Nursing laws and regulations.