Registered Nurse II

Job Description

Duties and Responsibilities:

• Responsible for clinical criteria prior authorization setup, which takes client clinical policy requirements and creates the prior authorization request sent to prescribers.
• This could include questions such as (but not limited to) is the patient 18, does this patient have , has the patient tried and failed these alternative medications etc.
• The creation of questions and answers along with other additional configuration will allow prescribers to answer questions leading to either an approval or denial.
• Clinicians are also responsible for creating and coding denial rationales sent to prescribers and patients.
• The system leveraged for this coding is a web-based platform proprietary to Client, and selected contractor will be trained on how to leverage this platform.
• Additionally, the individuals should have strong skills with Microsoft office, particularly Excel.
• Configuration support will be for both pharmacy and medical criteria and will require good creative problem solving skills to ensure appropriate setup to meet client needs and maximum operation efficiency.
• Consultative support in explaining setup and system requirements might be needed if discussing criteria setup with other internal Client business partners.
• An individual with strong and effective communication skills is highly desired.

Certifications & Licenses:

• RN license.
• Current RN Licensure in good standing as required by the state in which work is performed.

Knowledge, Skills and Abilities:

• Communication, Microsoft Office, Organization, Self-Driven, Collaboration.
• Attention to detail.
• Demonstrates ‘Team Player’ and collaborative skills within internal and external teams.
• Takes risks by thinking strategically about problems and challenges within their domain.
• Communicates effectively within peer group and subordinate groups.
• Holds oneself accountable for designated client relationships and the delivery of requests associated to service.
• Capable of & develops robust operational controls to maximize service levels.
• Able to identify the needs of clinical system or process changes to help enhance service levels.
• Ability to comprehend and articulate the importance of assigned responsibilities and controls.
• Able to mitigate concerns of business partners within direct Product of responsibility.
• Able to clearly communicate directly with clients when providing consultative services.

Schedule Hours Per Week: 40.00
Schedule Hours Per Day: 8.00
Schedule Days Per Week: 5.00