Registered Nurse(Medi-Cal)- 100% Remote

Company: Magellan Health Services
Location: San Jose
Posted on: May 15, 2022

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.

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