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

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

4d•Hybrid

About The Position

The Registered Nurse, Rx Refill and Prior Authorization Specialist supports prescription refill services and medication prior authorizations for the Behavioral Health Navigation Center. The role serves as an escalation contact for medication refill work queues and prior authorization requests, provides an exceptional patient experience, and ensures patients receive appropriate refill support. The position is hybrid between remote work and Broadhead Rd. The nurse also mentors and supports Rx Refill Specialists and collaborates with providers, practices, patients, pharmacies, insurers, and other internal teams.

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 telephone patient interactions.
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 telephone 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 when requests are flagged for review.
Use established escalation workflows to notify prescribing providers when refill 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, procedure, and testing prior authorizations through online, fax, and telephone channels, and document medication authorizations in the medical record as needed.
Provide patients and providers with updates and seek additional information during the prior authorization process.
Communicate required clinical information to insurance representatives to secure prior authorizations when necessary.
Document relevant information in medical records and notify patients of overdue visits or required screenings according to protocol when applicable.
Escalate medication questions and concerns to leadership or a designee as needed.
Partner with team members to address patient requests and concerns originating in other settings, including the Behavioral Health Navigation Center and practice operations.
Serve as a subject matter resource for team members and internal customers, research complex issues, and work with support resources to resolve patient issues.
Act 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 on staffing plans, daily staffing adjustments, and supply-and-demand monitoring to maintain service levels.
Maintain working relationships with practices to support an efficient prescription refill process.
Communicate with the Behavioral Health Navigation Center about refills, refill denials, medication questions, and pharmacy communications.
Analyze procedures and recommend improvements to the Senior 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 of controlled substances being refilled through multiple providers or locations.
Perform other duties as assigned.