Reviews requests for authorization for specific medications by reviewing medical records and documents related to the Medi-Cal program. Considers each prior authorization request and collects evidence and patient information to support the decision. Communicates with the prescriber and pharmacy to obtain additional information if needed. Ensures the authorization meets contractual obligations. May also require coordinating with administrators and healthcare providers to gain necessary information and ensures that patients receive authorized prescriptions.
As a key clinical member of the service center team, interacts with prescribers and pharmacy staff to review prior authorization requests and make appropriate determinations.
Consults with physicians/providers as necessary, interprets clinical guideline criteria, and renders/reviews coverage determination for prior authorization cases.
Consults with pharmacy staff regarding use of medications and recommend appropriate formulary alternatives when requested.
Gathers complex clinical information, coverage policy and criteria information and works within regulatory guidelines to make coverage determinations.
Performs all duties and functions in compliance with state and federal pharmacy laws and regulations.
Conforms with and supports department quality assurance and improvement guidelines.
Other Job Requirements
Responsibilities
Current/Active, unrestricted RN license in the State of California.
Minimum of 5 years of clinical nursing experience in a hospital, acute care, home health/hospice, or direct care environment.
Experience interpreting medical guidelines and drug compendia.
Experience with drug classes, dosages and usage.
Experience with medical terminology and diagnoses.
Intermediate to advanced computer skills and ability to quickly learn and adapt to new technology.
Proficient with Microsoft Office (Outlook, Word, Excel) and web-based navigation.
General Job Information
Title
Senior Utilization Management and Prior Authorization Nurse
Grade
26
Work Experience - Required
Clinical, Utilization Management
Work Experience - Preferred
Health Plans, Medicaid, PBM (Pharmacy Benefit Management)
Education - Required
Associates - Nursing
Education - Preferred
Bachelors - Nursing
License and Certifications - Required
RN - Registered Nurse, State and/or Compact State Licensure - Care Mgmt
License and Certifications - Preferred
Magellan Health, Inc. is proud to be an Equal Opportunity Employer and a Tobacco-free workplace. EOE/M/F/Vet/Disabled.Every employee must understand, comply with and attest to the security responsibilities and security controls unique to their position; and comply with all applicable legal, regulatory, and contractual requirements and internal policies and procedures.
