Position: Licensed Practical Nurse -Prior Authorization - Fully Remote
Location: Fully Remote
Duration: 12+ months (with a high possibility of extension)
Shift
Training schedule: Monday - Friday, 8:00 AM - 4:30 PM CST.
After training: Eight-hour shifts, Monday - Friday, between 8:00 AM and 12:00 AM CST, with possible weekend requirements.
Job Summary
As a Licensed Practical Nurse (LPN) or Licensed Vocational Nurse (LVN), you will utilize advanced clinical expertise to deliver high-quality, evidence-based patient care. Responsibilities include assessing patient needs, administering treatments and medications, collaborating with interdisciplinary teams, and advocating for patients. Your critical thinking and clinical knowledge will help support improved patient outcomes and enhance healthcare delivery.
Duties
Answer inbound calls and process cases, electronic authorizations, and specialty medication prior authorization requests.
Load authorizations, make follow-up calls, and communicate authorization status to physician offices, pharmacies, members, and internal departments.
Manage incoming faxes and process requests in accordance with departmental and client requirements.
Review criteria-based prior authorizations following established policies and procedures.
Maintain complete, accurate, and timely documentation through computer system data entry, data management, and reporting.
Research and triage incoming fax requests, use eligibility systems, and create, route, and/or complete appeals or requests according to departmental processes.
Process External Review appeal requests in accordance with federal, client, and state-mandated guidelines.
Refer cases that do not meet clinical criteria and clinical judgment questions to the appropriate Pharmacist and MD teams.
Provide on-call after-hours nurse availability for urgent prior authorization requests when required.
Provide internal nurse support to the Prior Authorization team and Member Services department.
Collaborate with Pharmacy Technicians, Pharmacists, and internal partners to resolve case-processing issues.
Act as a subject matter expert, assist with Coordinator duties, and support or mentor Coordinator staff as needed.
Help develop work instructions and promote process improvements.
Manage shifting priorities with urgency while maintaining professional and courteous communication.
Participate in rotating weekend coverage when required.
Complete other prior authorization assignments as delegated by the PA leadership team.
Experience
1–3 years of related experience.
Prior authorization experience in an MDO, PBM, or clinical setting is required.
Experience with case processing, calls, fax requests, documentation, and electronic authorizations.
Strong verbal and written communication skills.
Education
Graduate of an approved Practical or Vocational Nursing program.
Must hold a full, active, and unrestricted LPN/LVN license in a U.S. state, territory, commonwealth, or the District of Columbia.