Utilization Management Specialist Pharmacy - Specialty Pharmacy

Job Responsibilities:

• Provides prior authorization support for Specialty medications specific to disease state as assigned.
• Prioritizes and organizes work to meet changing priorities.
• Utilizes analytical ability required to gather data. Uses clinical judgment to apply predetermined criteria or uses independent clinical judgment when no predetermined criteria exists to identify problems and facilitate resolution.
• Uses independent clinical judgment in reviewing records to determine appropriate off label use of specialty medication, if proper procedures have been followed, appropriate escalation of PA denials through the appeals process.
• Makes recommendations regarding appropriateness of the treatment plan specific to the nurse’s assigned disease state.
• Contacts Physician’s office regarding questions, concerns or problems with the prescription before providing authorization support to other groups so that errors or discrepancies are corrected early in the workflow, making the process more efficient for other groups.
• Completes prior authorizations for assigned patients with a minimum as deemed appropriate by Manager.
• Applies clinical studies or guidelines accurately to monitor appropriateness of medications specific to each disease state.
• Follows department guidelines on escalation processes and refer cases appropriately to pharmacists, teams and manager.
• Maintains professional work standards including confidentiality, ethical principles, and professional work habits.
• Maintains and supports collaborative relationships with Physicians and the multidisciplinary team.
• Documents appropriately in Epic Specialty Encounter notes to provide evidence that the Prior Authorization process for the case was followed.
• Attends all staff meeting when scheduled to work.
• Other duties as assigned

Education:

• Graduate of an accredited school of nursing with licensure as a Registered Nurse (RN) in the State of Ohio.
• Bachelor of Science in Nursing preferred.

Certifications:

• Current valid license in the State of Ohio as a Registered Nurse (RN).

Competencies (Complexity of Work):

• Requires critical thinking skills, decisive judgment and the ability to work with minimal supervision
• Must be able to work in a stressful environment and take appropriate action

Work Experience:

• Requires three years equivalent full-time clinical experience as a Registered Nurse.
• Prior Utilization Management experience is preferred.
• Knowledge of medical terminology, anatomy and physiology, diagnosis, surgical procedures, and basic disease processes.
• Analytical ability required to gather data, decide on conformity based on predetermined criteria, identify problems and refer for resolution.
• Proficient with Epic.
• Awareness of licensing and accreditation standards.
• Proficient with Microsoft Office.
• Knowledge of prescription benefit and prior authorization requirements for specialty medications, adequacy of documentation, and ability to conduct research of issue at hand, as well as formulate recommendations based on findings; capable of providing in-service education to health care providers on this topic.
• Must possess advanced interpersonal and communication written and verbal skills necessary to gather and exchange data (both internally and externally) with members of the health care team.

Physical Requirements:

• Requires walking, sitting, and/or standing for long periods of time.
• Requires constant attention to detail, reading of medical records, and meeting deadlines.
• Works in an environment where there is some discomfort due to dust, noise, temperature.

Personal Protective Equipment:

• Follows standard precautions using personal protective equipment as required