Registered Nurse(Medi-Cal)- 100% Remote
Company: Magellan Health Services
Location: San Jose
Posted on: May 15, 2022
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Job Description:
Reviews requests for authorization for specific medications by
reviewing medical records and documents related to the Medi-Cal
program. Considers each prior authorization request and collects
evidence and patient information to support the decision.
Communicates with the prescriber and pharmacy to obtain additional
information if needed. Ensures the authorization meets contractual
obligations. May also require coordinating with administrators and
healthcare providers to gain necessary information and ensures that
patients receive authorized prescriptions.
* As a key clinical member of the service center team, interacts
with prescribers and pharmacy staff to review prior authorization
requests and make appropriate determinations.
* Consults with physicians/providers as necessary, interprets
clinical guideline criteria, and renders/reviews coverage
determination for prior authorization cases.
* Consults with pharmacy staff regarding use of medications and
recommend appropriate formulary alternatives when requested.
* Gathers complex clinical information, coverage policy and
criteria information and works within regulatory guidelines to make
coverage determinations.
* Performs all duties and functions in compliance with state and
federal pharmacy laws and regulations.
* Conforms with and supports department quality assurance and
improvement guidelines.
Other Job Requirements
Responsibilities
* Current/Active, unrestricted RN license in the State of
California.
* Minimum of 1 year of clinical nursing experience in a hospital,
acute care, home health/hospice, or direct care environment.
* Experience interpreting medical guidelines and drug
compendia.
* Experience with drug classes, dosages and usage.
* Experience with medical terminology and diagnoses.
* Intermediate to advanced computer skills and ability to quickly
learn and adapt to new technology.
* Proficient with Microsoft Office (Outlook, Word, Excel) and
web-based navigation.
* Bachelor of Science in Nursing.
* Experience in Clinical Contact Center environment.
* Experience working with Medicaid.
* Previous experience working within a PBM or Health Insurance
Plan.
* Experience in Utilization Management (UM), Prior Authorization or
Case Management.
General Job Information
Title
Registered Nurse(Medi-Cal)- 100% Remote
Grade
23
Work Experience
Clinical, Health Plans, Medicaid, PBM (Pharmacy Benefit
Management), Utilization Management
Education
Associates: Nursing (Required), Bachelors: Nursing
License and Certifications - Required
RN - Registered Nurse, State and/or Compact State Licensure - Care
Mgmt
License and Certifications - Preferred
Magellan Health, Inc. is proud to be an Equal Opportunity Employer
and a Tobacco-free workplace. EOE/M/F/Vet/Disabled.
Every employee must understand, comply with and attest to the
security responsibilities and security controls unique to their
position; and comply with all applicable legal, regulatory, and
contractual requirements and internal policies and procedures.
Keywords: Magellan Health Services, San Jose , Registered Nurse(Medi-Cal)- 100% Remote, Healthcare , San Jose, California
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