Clinical Utilization Nurse

CSI Companies•Plano, TX

11d•$88,000 - $115,000•Hybrid

About The Position

At CSI Pharmacy (CSI), we are on a mission to provide Specialty Pharmacy services to patients with chronic and rare illnesses in need of complex care. CSI is a rapidly growing national Specialty Pharmacy. Whether you work directly with patients or behind the scenes in support of the business and its employees, you will use your expertise, experience, and skills to support our patients and our mission. Summary The Clinical Utilization Nurse (CUN) is responsible for reviewing patient referrals/information to determine if diagnosis and clinical documentation support the use of the prescribed products. This clinician writes and/or reviews LMN templates to support obtaining authorization for treatment. The CUN coordinates and responds to requests for services for patients. This position communicates telephonically with sales team, prescribers, other departments, and with patients to ensure all necessary information required to support treatment with prescribed therapy is obtained. Makes admission/authorization decisions based on established policies, procedures, guidelines, and infusion experience. This position ensures that clinical reviews for prior authorizations requests are completed in a timely fashion to meet contractual requirements and are conducted using nationally recognized and evidence-based standards. This clinician also may perform an initial patient assessment and develop the initial Care Plan. The clinician leads patient monitoring efforts and outcome measures as directed by the Director, Clinical Utilization (DCU). Participates in Quality Improvement Projects, performs audits of medical records, and assists in preparation for audits and other regulatory activities as directed. They attend to the patient’s needs with utmost patience, care, compassion, and understanding.

Requirements

Provide the highest level of professionalism, responsiveness, and communication to build and maintain the maximum customer base possible.
Must possess the ability to multi-task and frequently change direction.
Must have and maintain a valid driver's license, maintain automobile insurance coverage, and have access to a reliable automobile.
Analytical - Uses intuition and experience to complement data.
Problem Solving - Identifies and resolves problems in a timely manner; Gathers and analyzes information skillfully; Develops alternative solutions; Works well in group problem solving situations; Uses reason even when dealing with emotional topics.
Technical Skills - Strives to continuously build knowledge and skills, Shares expertise with others.
Is proficient in cloud-based systems of communication and documentation such as Monday.com, MS-teams, etc.
Customer Service - Manages difficult or emotional customer situations; Responds promptly to customer needs; Solicits customer feedback to improve service; Responds to requests for service and assistance.
Interpersonal Skills - Focuses on solving conflict, not blaming; Maintains confidentiality; Listens to others without interrupting; Keeps emotions under control; Remains open to others' ideas and tries new things.
Oral Communication - Speaks clearly and persuasively in positive or negative situations; Listens and gets clarification; Responds well to questions.
Written Communication - Writes clearly and informatively; Able to read and interpret written information.
Teamwork - Exhibits objectivity and openness to others' views; Gives and welcomes feedback; Contributes to building a positive team spirit.
Business Acumen - Conserves organizational resources.
Diversity - Demonstrates knowledge of EEOC policy; Shows respect and sensitivity for cultural differences; Supports affirmative action and respects diversity.
Ethics - Treats people with respect; Works with integrity and ethically; Upholds organizational values.
Organizational Support - Follows policies and procedures; Supports affirmative action and respects diversity.
Planning/Organizing - Uses time efficiently.
Professionalism - Approaches others in a tactful manner; Reacts well under pressure; Treats others with respect and consideration, regardless of their status or position; Accepts responsibility for own actions; Follows through on commitments.
Quality - Demonstrates accuracy and thoroughness; Looks for ways to improve and promote quality; Monitors own work to ensure quality.
Safety and Security - Observes safety and security procedures; Reports potentially unsafe conditions; Uses equipment and materials properly.
Adaptability - Able to deal with frequent change, delays, or unexpected events.
Attendance/Punctuality - Is consistently at work and on time.
Dependability - Follows instructions, responds to management direction.
Initiative - Asks for and offers help when needed
Associates degree or Bachelor’s degree from an accredited nursing school as a Registered Nurse (RN), or Nurse Practitioner (NP)
Maintains certification as a registered nurse/ nurse practitioner from a Board recognized national certification organization, which requires the passing of a national certifying examination in the specialty in which the applicant is seeking certification by the Board
At least two (2) years clinical experience
Strong organizational skills and a thorough knowledge of computers (Microsoft Office and Windows) are required
Demonstrated ability to work independently and meet goals
Clinical Skills, Strong knowledge-base in infusion, experience providing immune globulin and other biologics Teamwork, Multi-tasking, Listening, Verbal Communication, Health Promotion and Maintenance

Nice To Haves

Previous Medicaid/Medicare experience preferred
Prior authorization/utilization review experience preferred
IgCN, CSP, or similar certifications relating to Specialty Infusions preferred

Responsibilities

Reviews and documents medical necessity for immune globulin, biologics, and other therapies as required for referrals.
Maintains knowledge of insurance companies’ requirements for authorization.
Reviews clinical documentation for supporting evidence of prescribed therapy for the patient’s diagnosis per established criteria prior to submission of authorization.
Demonstrates a high degree of responsibility regarding accuracy and quality of work.
Maintains an accurate and up to date filing system for medical necessity and pertinent citations and sources by disease process and specialty in the shared company drive
Documents current clinical data on the patient’s profile, completes the initial patient assessment and starts care plan.
Reviews denied prior authorizations and appeals when appropriate.
Drafts LMN (Letter of Medical Necessity)
Drafts appeal letter, when applicable
Works closely with prescribers and their staff to coordinate patient care during the prior authorization process and/or appeals process
Research requests not clearly meeting established criteria
Reviews prior authorizations generated by the Benefits Investigation Specialist or Insurance Verification Specialists
Utilizes Cover My Meds (CCM) to draft prior authorizations
Collaborates with other referral teams, such as Intake, Patient Care Coordination, and pharmacy to ensure complete patient care.
Conducts disease specific clinical assessments, as applicable
Promotes patient's independence by establishing patient care goals; teaching patient, friends, and family to understand condition, medications, and self-care skills; answering questions
Assures quality of care by adhering to therapeutic standards; measuring health outcomes against patient care goals and standards; making or recommending necessary adjustments; following pharmacy and infusion site philosophies and standards of care set by state board of nursing/pharmacy, state nurse/pharmcy practice act, and other governing agency regulations
Monitors RTM and RPM programs and contacts patients enrolled on a routine basis to ensure medical compliance, quality, and outcomes.
Communicates, when necessary, with treating physicians care team.
Shares outcomes and monitoring data with CMO and clinical treatment team.
Maintains continuity among teams by documenting and communicating actions, irregularities, and continuing needs
Maintains patient confidence and protects operations by keeping information confidential
Maintains effective working relationships and cooperates with all personnel in the Company.
Adheres to the Company’s compliance requirements as stated in the policy and procedure manual and all other related policies.
Performs other compliance duties and responsibilities as assigned