Registered Nurse, Rx Refill and Prior Authorization Specialist- Behavioral Health Navigation Center

St. Luke's University Health Network•Bethlehem, PA

6d•Hybrid

About The Position

The Registered Nurse, Rx Refill and Prior Authorization Specialist supports the Behavioral Health Navigation Center by delivering an exceptional patient experience and helping ensure patients receive appropriate prescription refill services. The nurse serves as an escalation contact for medication refill work queues and medication prior authorization requests, responds to refill requests according to center and pharmacy procedures, and escalates medication concerns and controlled-substance matters to practices and providers. The role also mentors and supports Rx Refill Specialists. The position is hybrid between remote work and the Broadhead Rd. location. The nurse processes refill and prior authorization requests, reviews records and refill protocols, coordinates with patients, providers, pharmacies, and insurers, documents activity in the medical record, and helps resolve complex issues. The nurse collaborates with the Behavioral Health Navigation Center and other teams to maintain service levels, support staffing and workflow, and improve the refill process.

Requirements

Graduate of an accredited nursing program.
Active Registered Nurse licensure in Pennsylvania.
At least three years of recent clinical experience in a pharmacy or related office.
Experience or familiarity with patient interactions by telephone.
Epic Cadence experience.
Ability to work from home in accordance with the Network Work from Home Policy, if needed.

Nice To Haves

Bachelor’s degree in nursing preferred.
At least two years of leadership or management experience preferred.

Responsibilities

Process incoming phone and electronic patient medication refill and prior authorization requests using electronic health records, patient engagement tools, and prescription refill platforms.
Interact with patients politely, promptly, and compassionately.
Review medical records and specialty-specific refill protocols for requests flagged for review.
Use defined escalation workflows to notify prescribing providers when requests do not meet protocol criteria.
Coordinate with patients, providers, insurance companies, and pharmacies to address medication refill requests.
Monitor prior authorization work queues and obtain or review insurance information and eligibility verification.
Obtain medication prior authorizations through online, fax, and telephone channels, and document them in the medical record as needed.
Seek additional information and provide updates to patients and providers during the prior authorization process.
Provide required clinical information to insurance representatives to secure prior authorizations when necessary.
Document relevant information in the medical record and, when applicable, notify patients of overdue visits or required screenings according to protocol.
Escalate medication questions and concerns to leadership or a designee as needed.
Partner with other team members to address patient requests and concerns that may originate in other settings.
Serve as a subject matter expert and resource for team members and internal customers; research complex issues and work with support resources to resolve patient issues.
Serve as an escalation point for clinical questions about prescription refills and medication prior authorizations, and complete escalated requests.
Collaborate with the Behavioral Health Navigation Center to plan and optimize staffing, adjust daily staffing, and monitor supply and demand to maintain service levels.
Maintain effective working relationships with practices to support an efficient refill process.
Communicate with the Behavioral Health Navigation Center about medication refills, denials, related questions, and pharmacy communication.
Analyze current procedures and suggest improvements to the Sr. Director, Referral Development and Patient Access, or appropriate leadership.
Support Rx Refill Specialists in following refill protocols and using external resources to verify refill appropriateness; inform providers about controlled substances being refilled through multiple providers or locations.
Perform other duties as assigned.