Drug Authorization RN

Location
Sandy Springs, Atlanta
Salary
excellent benefits
Posted
Feb 12, 2018
Closes
Mar 12, 2018
Specialty
Hemo / Oncology
Contract Type
Permanent
Hours
Full Time

DrugAuths RN Duties:.

  1.  Review each incoming drug precert that comes into the DrugAuths Inbox to determine if it meets insurance company, FDA and/or NCCN guidelines to clinical clear
    1. Clinically clear all chemo/drugs requests by ensuring that the patient meets any clinical criteria (beyond dx code) that the Drug Auths IVU reps cannot clear solely on patient diagnosis
    2. Review and confirm that Site Nurses complete prior authorization forms and have the accurate clinical information and questions answered correctly
    3. Initiate all authorizations for all drugs that require a Prior Authorization either using the online tools per plan or faxing forms with documentation from the patients’ medical record
    4. Initiate predetermination/prior authorizations requests for high cost drugs for all BCBS out of state plans and other commercial insurance plans that allow. These are not required but done to avoid denials after claims have been filed for drugs where a prior authorization is not required
    5. If a patient is not cleared, provide the non-clinical IVU rep with verbiage for the rationale for non-clearance (sent to Nurses to explain to MD/APP)
  2. Initiate authorizations for all Genetic Tests
  3. Initiate authorization requests for all BCBS PET scans, other STAT scan requests, Echos or any scans where the hospital or facility cannot initiate
  4. Compile and Communicate the peer to peer information for scans, drugs, procedures – attach the procedure policy to the email for MD/APP to use in the Peer to Peer calls
  5. Track and obtain Reauthorizations of any drugs that require prior auth, fill out necessary forms, review forms coming from IVU from the clinic nurses for accuracy/completeness, compile medical records as needed
  6. Compile Medical records for Case managers as necessary related to new treatment requests
  7. Provide  business office with Letters of Medical necessity, medical records, explanations and rationale when they send a Grid over for responses – Done in conjunction with Business office Director
  8. Generate Appeal Letters as needed with supporting clinical information/literature search prospectively for new treatment or retrospectively for denied claims
  9. Provide clinical support/info as needed to all Business office staff, clinical staff, as well as outside reviewers
  10. Compile and update prior auth requirement lists for all insurance plans including sending the updated forms to nurses (as plans update). 
  11. Review and provide feedback re: Ins plan newsletters with drug and other  clinical changes to Business office Director to respond to managed care for contracting and to decide if pushing back on plans is necessary
  12. Training of New Staff (PSRs, RNS, etc) on the precert and scan authorization request process
  13. Keep Compliance forms for all staff – complete a compliance report each year

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