Prior Authorization Nurse Coordinator

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