UM Medication Prior Authorization Nurse (Remote) Greater Louisville candidates only will be con sidered
About The Position
The UM Medication Prior Authorization Nurse reviews cases and applies medical criteria to evaluate and submit authorizations to MCOs, Medicare, and commercial insurance companies based on medical necessity. The role collaborates with site providers and nurses, pharmacies, and insurers to advocate for clients and meet their needs. It interprets medication denials and provides guidance and education to site providers, while also communicating medication formulary requirements to providers and nurses. The position conducts chart audits for medical necessity, quality, and compliance; reviews utilization-management reports for outstanding and expiring authorizations; documents and maintains accurate communication records; and maintains a centralized knowledge base of formularies and prior-authorization requirements. It also provides data and trends on medication denials and approvals to medical leadership. Staff are expected to demonstrate principle-centered leadership, responsive customer service, continuous quality improvement, and knowledge of applicable safety-management policies and Joint Commission standards.
Requirements
- Completion of a certified nursing program.
- Five or more years of clinical experience.
- Active and unencumbered Kentucky Board of Nursing LPN or RN license.
Nice To Haves
- At least one year of utilization case management experience.
Responsibilities
- Review cases and apply medical criteria to evaluate and submit authorizations to MCOs, Medicare, and commercial insurance companies based on medical necessity.
- Collaborate with site providers and nurses, pharmacies, and insurance companies to advocate for and meet client needs.
- Interpret and communicate medication denials to site providers, offering guidance and education.
- Provide ongoing education to site providers and nurses about medication formulary requirements.
- Conduct chart audits for medical necessity, quality, and compliance standards.
- Review utilization-management reports for outstanding and expiring authorizations.
- Document and maintain accurate records of all communications.
- Maintain a centralized knowledge base of formularies and prior-authorization requirements.
- Provide data and trends on medication denials and approvals to medical leadership.
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What This Job Offers
Job Type
Full-time
Education Level
No Education Listed
