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Medication Prior Authorization Nurse
Seven Counties Services. Review cases and apply medical criteria to evaluate and submit authorizations to MCOs, Medicare, and commercial insurance companies based on medical necessity .
Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in clinical evaluation and authorization processes, with a strong focus on medication management, compliance standards, and effective communication with healthcare providers. Proven ability to lead initiatives that enhance customer service and quality improvement in healthcare settings.
Highest-signal resume keywords
Clinical ExperienceUtilization Case ManagementMedication Prior Authorization EvaluationChart Audits for Medical NecessityKentucky LPN or RN License
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Medical Criteria EvaluationAuthorization SubmissionChart AuditsQuality Compliance StandardsData AnalysisMedication Formulary KnowledgeUtilization Management ReportingRecord Maintenance
Soft Skills
CommunicationCollaborationAdvocacyEducation
Certifications & Qualifications
Certified Nursing ProgramKentucky Board of Nursing License
Industry Keywords
Medical NecessityJoint Commission StandardsSafety ManagementMedication DenialsContinuous Quality Improvement
About the role
Key responsibilities & impact- Review cases and apply medical criteria to evaluate and submit authorizations to MCOs, Medicare, and commercial insurance companies based on medical necessity
- Collaborate with site providers, nurses, pharmacies, and insurance to advocate for and meet client needs
- Interpret and communicate medication denials with site providers, offering guidance and education
- Communicate with site providers and nurses to provide ongoing education about medication formulary requirements
- Conduct chart audits for medical necessity, quality, and compliance standards
- Review utilization management reports for outstanding and expiring authorizations
- Document and maintain accurate records of all communications
- Maintain a centralized knowledge base of formularies and prior authorization requirements
- Provide data and trends to medical leadership regarding medication denials and approvals
- Exercise principle-centered leadership focused on customer service responsiveness and continuous quality improvement
Requirements
What you’ll need- Completion of certified nursing program
- Five plus years of clinical experience
- At least one year of utilization case management preferred
- Kentucky Board of Nursing active and unencumbered LPN or RN license
- Greater Louisville candidates only will be considered
- Knowledge of policies and procedures related to safety management and Joint Commission standards
- Ability to review medical criteria and evaluate medication prior authorizations
- Ability to communicate medication denials and provide guidance and education
- Ability to conduct chart audits for medical necessity, quality, and compliance standards
- Ability to maintain accurate records and centralized knowledge of formularies and prior authorization requirements
Benefits
Comp & perks- Remote work arrangement