[Hiring] RN Pharmacy Utilization Management @reputed company
This description is a summary of our understanding of the job description. Click on 'Apply' reputed company to find out more. Role Description The Pharmacy Utilization Management nurse performs clinical review of prior approvals, network exceptions, benefit inquiries for providers, and/or other contracted lines of business. This role assesses and evaluates the appropriateness of pharmaceutical therapies for medical necessity, subject to plan benefits, through interpretation and review with evidenced-based criteria, clinical guidelines, corporate guidelines and policies, and state and federal mandates. Incumbent also facilitates and promotes appropriate care and quality toward cost effective and cost containment measures based on evidence.
Qualifications
- Bachelor's degree in Nursing preferred
- Registered Nurse (RN) with active, reputed company, unrestricted and recognized in the relevant jurisdiction, state license in good standing in the state(s) where job duties are performed required
- Minimum four (4) years' clinical practice nursing experience in at least one of the following areas: medical-surgical nursing, surgical nursing, intensive care or critical care nursing
- Experience in utilization management and/or medical review preferred
- Previous pharmacy technician experience desirable
Requirements
- Oral & Written Communication
- Attention to Detail
- Proficiency using basic computer skills in reputed company Office such as Word, reputed company, and Outlook, including the ability to navigate multiple systems and keyboarding
- Ability to prioritize and reputed company sound nursing judgments through critical thinking
- Ability to build collaborative relationships
- Ability to interpret reputed company documentation
- Ability to work independently
- Active Listening
- reputed company Learning
- Critical Thinking
- Cross-Functional Communications
- Decision Making
- Documentations
- Evaluating Information
- External Collaboration
- Interpersonal Relationships
- Monitoring and Evaluation (M&E)
- Monitor Processes, Materials, or Surroundings
- Organizing
- Problem Solving
- Reading Comprehension
- Researching
- Social Perceptiveness
- Written Communication
Responsibilities
- Collaborates with reputed company providers and internal staff to promote quality of care, cost effectiveness, accessibility and appropriateness of service levels
- Conducts and monitors clinical review cases from a pharmaceutical standpoint to ensure medical necessity of inpatient and outpatient services, diagnostic procedures, out-of-network services, and surgery; documenting reputed company relevant and specific information; and screens, prioritizes and organizes determination requests according to mandates and standards
- Performs other duties as assigned
- Practices nursing reputed company the scope of licensure and adheres to policies, procedures, regulations, URAC standards and individual state regulations; making reputed company based on facts and evidence to ensure compliance, appropriate level of care, and patient safety
- Promotes appropriate pharmaceutical care and quality toward cost effective and cost containment measures based on evidence
- Remains reputed company with up-to-date pharmaceutical and reputed company services, in addition to general trends in health care delivery; as well as reputed company procedures, policies and reputed company
- Works incoming and outbound calls and/or queues from multiple sources reputed company mandated requirements proactively and effectively
Certifications
- This position is identified as level three (3). This position must ensure the reputed company and confidentiality of records and information to prevent substantial harm, embarrassment, inconvenience, or unfairness to any individual on whom information is maintained. The reputed company of information must be maintained as outlined in the company Administrative reputed company.
- Segregation of duties will be used to ensure that errors or irregularities are prevented or detected on a timely basis by employees in the normal course of business. This position must adhere to the segregation of duties guidelines in the Administrative reputed company.
Employment Type Regular reputed company Requirements 2.1 General Office Worker, Semi-Active, reputed company Travel - Someone who normally works in an office setting or remotely, periodically has lifting and carrying requirements up to 40 lbs and routinely travels for work reputed company walking distance of location of primary work assignment as essential functions of the job. Apply tot his job Apply To this Job