About the position
Ann & Robert H. Lurie Children’s Hospital of Chicago provides superior pediatric care in a setting that offers the latest benefits and innovations in medical technology, research and family-friendly design. As the largest pediatric provider in the region with a 140-year legacy of excellence, kids and their families are at the center of all we do. Ann & Robert H. Lurie Children’s Hospital of Chicago is ranked in all 10 specialties by the U.S. News & World Report. Location 680 Lake Shore Drive Job Description This is a remote position that requires mandatory travel to the Lurie Main Hospital campus once per month. Must work 8 hours per day with a flexed start time available. Must have an Illinois RN license and 3 years of practice experience in Peds, Ambulatory, or Prior Authorization to receive an interview. Experience using EPIC electronic medical record preferred. General Summary: The Prior Authorization Nurse Coordinator coordinates the activities which pertain to the Prior Authorization Department. The Nurse Coordinator is responsible for ensuring all in-scope medication prior authorizations are completed across the organization as well as facilitating imaging related pre-certifications that have escalated to a peer-to-peer or clinical appeal level. The Nurse Coordinator is responsible for providing the necessary supporting documentation in collaboration with a group of diverse health care providers.
Responsibilities
• Coordinate the activities which pertain to the Clinical Prior Authorization Department.
• Obtain medication prior authorizations from insurance entities utilizing Covermymeds in accordance with standard written procedures, guidelines, and state and federal regulations while also, maintaining compliance to medical record confidentiality regulations.
• In coordination with the Financial Clearance team, this RN will manage peer to peer escalation cases for pre-certification and appeals for imaging denials.
• Manage correspondence with insurance entities, physicians, specialists, and patients as required and ensuring all necessary supporting documentation is provided for approvals.
• Manage denials and submit appeals, ensuring all necessary supporting documentation is provided to get them approved from insurance entities.
• Create accurate and consistent documentation in patient’s records to ensure that prior authorization information is properly updated.
• Record all prior authorization phone calls, documents and authorization numbers in EPIC utilizing the patient chart and referral module.
• Utilize the patient medical record to submit supporting clinical records and/or providing verbal medical necessity validation and support for pending pre-certifications.
• Manage physical medical records and utilization management documentation from insurance entities to support approval of pre-certifications.
• Self-driven and motivated to work independently for the purpose of utilizing resources to expand knowledge base on drug information and basic pathophysiology.
• Acts as a resource to hospital personnel with regard to the care and coordination of medication prior authorizations as well as pre-certifications and troubleshooting pharmacy end issues as it relates to confirming the pharmacy is able to obtain paid claims.
• Other job functions as assigned.
Requirements
• A BSN degree from an accredited school of nursing and current licensure as a registered professional nurse in the State of Illinois required.
• Three years of relevant nursing experience.
• Must demonstrate the ability to problem solve and support teamwork in a multidisciplinary setting in a positive and professional manner.
• The candidate must demonstrate excellent written and verbal communication skills.
• Knowledge of online authorization systems and status review and ability to track in-process authorizations from multiple sources.
• Computer skills required.
Nice-to-haves
• Master's prepared preferred.
• With a minimum of 1 year of medication prior authorization and/or pre-certification experience preferred.
• Experience working in partnership with health care professionals and support staff in an office setting is necessary.
• Proficient in Microsoft Office applications preferred.
• Experience using EPIC electronic medical record preferred.
Benefits
• For full time and part time employees who work 20 or more hours per week we offer a generous benefits package that includes:
• Medical, dental and vision insurance
• Employer paid group term life and disability
• Employer contribution toward Health Savings Account
• Flexible Spending Accounts
• Paid Time Off (PTO), Paid Holidays and Paid Parental Leave
• 403(b) with a 5% employer match
• Various voluntary benefits: Supplemental Life, AD&D and Disability Critical Illness, Accident and Hospital Indemnity coverage
• Tuition assistance
• Student loan servicing and support
• Adoption benefits
• Backup Childcare and Eldercare
• Employee Assistance Program, and other specialized behavioral health services and resources for employees and family members
• Discount on services at Lurie Children’s facilities
• Discount purchasing program