Education: The Licensed Practical Nurse is a graduate of a school of Practical or Vocational Nursing, approved by the State Agency and/or accredited by the National League for Nursing (Accrediting Commission (NLNAC)) at the time the program was completed by the applicant. The LPN/LVN must have a full, active, and unrestricted license as a Licensed Practical or Vocational Nurse in a State, Territory, or Commonwealth of the United States or District of Columbia.
Experience
Hold and maintain an active LPN/LVN license in the state of practice.
Minimum 1 year of experience reviewing and processing prior authorizations against health plan criteria for a determination in a clinical setting (medical office or Pharmacy Benefits Manager - PBM).
3 to 5 years of prior related work experience as an LPN/LVN in a medical office, PBM, or clinical setting.
Experience using MS Office, other Windows-based computer applications, and phone use.
Job Description: As a Remote Licensed Practical Nurse (LPN/LVN) specializing in Prior Authorization, you will be responsible for reviewing complex clinical criteria-based prior authorizations in accordance with CVS/Caremark policies and procedures. This role involves collaboration with various teams, excellent communication skills, and the ability to navigate a fast-paced and changing environment.
Refer cases not meeting clinical criteria for upper-level review when appropriate.
Exhibit a high level of urgency and responsiveness with calls, prior authorization requests, and ADHOC assignments.
Follow all prior authorization procedures, ensuring compliance with regulatory requirements and accreditation standards.
Participate in ongoing quality assurance activities, including reviewing work instructions and job aids regularly.
Collaborate with representatives on the prior authorization team, pharmacists, clinical colleagues, healthcare professionals, clients, leaders, and team members.
Utilize clinical and problem-solving skills to support the research of documentation, communication of medical services, and prior authorization determinations.
This position is a 100% remote, work-from-home opportunity and will not involve direct patient interaction.
Note: The schedule may vary, and the colleague may be required to work business-required overtime, weekends, and make outreach, and process prior authorization requests based on business needs.
Skills And Qualifications
Strong communication skills, both written and verbal.
Ability to shift priorities and exhibit urgency in a fast-paced environment.
Proficiency with computer skills, multitasking, navigating multiple systems, and keyboarding.
Experience in reviewing and processing prior authorizations in a clinical setting.
Knowledge of health plan criteria for determinations.
Experience with MS Office, other Windows-based computer applications, and phone use.
If you meet the qualifications and are looking for a challenging and rewarding role as a Remote Licensed Practical Nurse in Prior Authorization, we encourage you to apply.
Seniority level
Mid-Senior level
Employment type
Contract
Job function
Health Care Provider
Industries
Hospitals and Health Care
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