Utilization Review Nurse chez Visante Consulting LLC

Description

ABOUT VISANTE

We are a specialized consulting firm focused on helping health systems accelerate strong financial and operational performance through pharmacy. Our team of professionals bring deep, contemporary expertise and innovation to optimizing all aspects of a fully integrated health system pharmacy program, driving significant value quickly.

Our mission is to transform healthcare through pharmacy, and our vision is to reimagine pharmacy to improve lives.

ABOUT THE POSITION

The Utilization Review Nurset is responsible for managing pre-claim prior authorization (PA) denials for both pharmacy and medical benefit across multiple clients. This role plays a key part in supporting patient access by identifying, resolving, and preventing delays in care related to insurance denials. The ideal candidate will have clinical expertise and experience navigating payer policies, formulary requirements, prior authorizations, medical necessity review, creation of letters of medical necessity, and appeals.

Principle Duties and Responsibilities 

• Review and assess prior authorization pre-claim denials (pharmacy and medical) for clinical appropriateness and appeal potential
• Utilizing   clinical chart documentation and evidenced base guidelines to prepare and submit timely clinical documentation and appeal letters to overturn denied authorizations 
• Communicate directly to providers to gather and refine clinical documentation supporting medical necessity or providing recommendations on alternative options
• Annalize pre-claim denial patterns to identify root cause and recommend preventative strategies
• Support the development of tools and workflows to reduce pre-claims denials
• Serve as a clinical resource to MAS staff for payer policy interpretation, documentation needs, and pre-claim denial prevention strategies
• Contribute to trend reporting and outcomes tracking related to pre-claim denials and appeals 

Requirements

Education

Required: Successful completion of an accredited Associate Degree in Nursing (ADN) program     

Preferred: Bachelor’s degree in Nursing   

License 

Required: RN licensure (NCLEX-RN) required prior to start date

Experience

Required:  2 years of experience in clinical practice, utilization or formulary management, prior authorization submission   

Special Skills: 

• Demonstrates strong clinical reasoning and critical thinking skills.
• Possesses excellent written and verbal communication skills.
• Maintains strong organizational skills, attention to detail, and the ability to manage multiple cases across clients.
• Works collaboratively as part of an interdisciplinary team.
• Experience navigating an electronic medical record (EMR) and payer portals with proficiency.

Compensation and Benefits: We offer competitive salary and benefits for this full-time salaried role. 

Equal Opportunity Statement: Visante is an equal opportunity employer. Visante’s people are its greatest asset and provide the resources that have made the company what it is today. Visante is, therefore, committed to maintaining an environment free of discrimination, harassment, and violence. This means there can be no deference because of age, religion or creed, gender, gender identity or expression, race, color, sexual orientation, national origin, disability, veteran status, or any other characteristic protected by applicable laws and regulations.