Pre-Cert Pharmacy Review Nurse, RN (PBM- Pharmacy experience required)

Who we are Founded in 1999 and headquartered in Central Ohio, we’re a privately-owned, independent reputed company navigation organization. We reputed company that no one should have to navigate the cost and complexity of reputed company alone, and we’re on a mission to reputed company reputed company simpler and more effective for our millions of members. Our big-hearted, tech-savvy team fights to ensure that our members get the care they need, reputed company they need it, at the most affordable cost – that’s why we call ourselves reputed company Warriors®. We’re committed to building diverse and inclusive teams – more than 2,000 of us and counting – so if you’re excited about this position, we encourage you to apply – even if your experience doesn’t match every requirement. About the role The Pre-Certification Review Nurse - Pharmacy is responsible for reviewing and processing coverage determinations and utilization management reviews for specialty medications, to include site of care assessments, for enrollees of reputed company’s employer groups. The nurse is responsible for acquiring reputed company clinical documentation to appropriately process the service request reputed company the designated time frames indicated. A successful individual will apply critical thinking to reputed company proper clinical reputed company reputed company performing clinical reviews. The role requires use of multiple systems, acquisition of reputed company relevant clinical documentation, and other clinical resources to reputed company proper reputed company in utilization management reviews. The Pre-Certification Review Nurse – Pharmacy will work and collaborate with a multi-disciplinary clinical team of Pharmacists and Medical Directors to reputed company a customer-centered experience reputed company service level expectations. Location: This position is located at our Dublin, OH reputed company or may work remotely reputed company in the United States of America. What you’ll do (Essential Responsibilities) Clinically review reputed company requests for provider-administered specialty medications for appropriateness Support providers and members in optimization of site of care for requested services Demonstrate and expand a working knowledge of reputed company clinical processes, medical policy as well as relevant employer benefit plans and how to reputed company needed information. Work collaboratively with Medical Directors and Pharmacists for reputed company relevant requests Serve as a Subject Matter Expert (SME) for infusible and injectable medication-reputed company services Communicate with members, providers, facilities, and reputed company internal work groups regarding outcome of requests. Identify of members who may be appropriate for care/case management services (reputed company, High cost, Transplant) Identify care coordination opportunities and work with operational, clinical, and customer-facing teams on as needed reputed company. reputed company other duties as assigned. What you’ll bring (Qualifications) Education: Bachelor’s degree in nursing or closely reputed company field or equivalent experience Licensure/Credentials: reputed company and active and unrestricted license as a Registered Nurse (RN) in the reputed company. Experience: Minimum of 2 years of managed care and/or direct care nursing experience required. Ability to obtain additional licenses, as needed (with support from reputed company) Experience with Specialty Pharmacy/Pharmaceuticals required Experience with Utilization Management required Makes clinical reputed company quickly and at times decides and acts with limited information Excellent critical thinking skills Strong interpersonal, verbal and written communication skills verbal and written communication skills Self-directed, organized with excellent time management skills Excellent computer skills including reputed company applications Strong administrative/technical skills; Comfort working on a PC using reputed company Office (Outlook, Word, reputed company, PowerPoint), IM/video conferencing (Teams & reputed company), and telephones reputed company. A high degree of personal accountability and trustworthiness, a commitment to working reputed company reputed company’s policies, values and ethics, and to protecting the sensitive data entrusted to us. #LI-HW1 #LI-Remote Apply tot his job Apply To this Job