Prior Authorization Nurse

Curant Health•Smyrna, GA

16h

About The Position

Do you want to join a leading healthcare team focused on nurturing long-term patient and caregiver relationships? Do you want to be a part of a company that is committed to hiring the best people and using the best technology and tools to deliver improved health outcomes for patients and partners? If so, take a look at the available career opportunities at Curant Health. Curant Health is searching for a Prior Authorization Pharmacist to join its team in Smyrna, GA. The Prior Authorization Pharmacist oversees clinical and operational aspects of specialty medication prior authorizations. This role involves processing and evaluating PA requests, supervising PA specialists, and serving as a clinical resource to both internal and external stakeholders.

Responsibilities

Perform duties primarily related to specialty medication prior authorization requests (i.e., biopharmaceuticals) according to established treatment protocols, clinical criteria, and member benefits.
Define and coordinate specialty medication prior authorization and drug utilization review reports for clients and ensure regulatory reporting requirements for drug utilization review, fraud and abuse reporting are met.
Interface with physicians, pharmacists, and specialty pharmacy providers with respect to beneficiaries’ benefits and therapeutic interventions and reviewing/evaluating the health surveys and utilization data for program management and development.
Support Customer Care with clinical calls requiring nurse intervention for medication-related prior authorizations.
Review initial PA requests according to published policies and procedures, applicable clinical criteria, and regulatory and compliance requirements.
Process PA appeals, including first level reviews, and coordinate second level appeals cases for review by the designated Appeals Vendor as required.
Serve as clinical and PA operational resource to internal and external customers/clients as required.
Continually monitor the quality and efficiency of the Coverage Determination process including coverage criteria, denial language, and communication with prescribers.
Responsible for staying current with clinical literature and guidelines, and relaying those to the program development core teams.
Have general understanding of and perform in compliance with the current Specialty Pharmacy URAC standards applicable to the position.
Perform other duties and responsibilities as assigned.