LPN/RN/MEDICATION PRIOR AUTH SPECIALIST

JOB SUMMARY TheR.N./LPN assumes responsibility/accountability for a group of patients for a designated time frame and provides care to these patients via therapeutic use of self, the nursing process, the environment, and other health care team members.

The Prior Authorization Specialist is responsible for obtaining prior authorizations for all procedural orders and medications by successfully completing the authorization process with all commercial payers, and specialty pharmacies.

Ages served range from pediatric to geriatric.

ESSENTIAL FUNCTIONS 1.

Responsible for planning, assessing, intervening, co-coordinating and providing direct patient care by utilizing critical thinking skills.

2.

Communicates with physicians, ancillary caregivers, patients and families regarding the patients plan of care.

3.

Communicates with patients on an age-appropriate level.

4.

Strong organization and leadership skills.

5.

Recognizes and meets the needs of special needs patients, physicians, visitors, and facility staff.

6.

Performs assessments including physical, psychosocial, nutritional, functional, safety, spiritual, cultural, and educational needs.

7.

Completes supporting documentation for supplies, medications, labs, charges, and equipment used.

8.

Contacts insurance companies to verify patients insurance eligibility, benefits and requirements.

9.

Requests, tracks and obtain prior authorizations from insurance carriers within time allotted for medications, testing, etc.

10.

The Prior Authorization Specialist is responsible for obtaining prior authorizations for all procedural orders by successfully completing the authorization process with all commercial payers, and specialty pharmacies 11.

Will be expected to work closely with the Rheumatology Nurse, Infusion nurse and pharmacy staff to ensure timely, high-quality, cost-effective care 12.

Verifies infusion order in the medical chart 13.

Prioritize incoming authorization requests and verification of benefits according to urgency 14.

Utilizes technology and resources (systems, telephones, etc.) to appropriately complete prior authorization activities 15.

Effectively and accurately communicates and documents prior authorization process to patients, providers, and department leadership 16.

Interact with providers to obtain additional clinical information and participate in the development and modification of medical necessity criteria 17.

Follows up on pending referrals, missing clinicals, and other items needed for criteria completion within a timely manner 18.

Verifies patient has completed necessary labs prior to infusion 19.

Documents in the clinic record (Chief Complaint, vitals, past medical history, medications, pharmacy, allergies, height, weight, smoking status, cessation offered if a smoker, fall risks, depression screenings and any other quality measures that are required by our organization 20.

Demonstrates competency in skills verified by Skills Check List.

21.

Demonstrates patient and associate ...