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Pharmacy Precert Nurse
3 months ago
Reporting directly to the Medical Director and indirectly to Medical Services, the Pharmacy Precert Coordinator supports our Workers' Compensation line of business by performing prospective and retrospective Utilization Review of pharmaceutical/medication requests in accordance with regulatory guidelines, where appropriate, and to ensure requests are clinically supported based upon NJM Medical Policies, standard professional treatment and/or evidence-based guidelines.
Job Responsibilities:
- Accurately and effectively evaluate the claim history and current medical records against NJM Medical Policies and evidence-based guidelines in order to determine whether medications are clinically appropriate and causally related.
- Evaluate requests that are routed for clinical review based upon established criteria to issue appropriate and timely determinations on initial and refill prescription requests.
- Determine if medication(s) can be authorized as medically necessary and causally related based upon file documentation, compliance with regulations, standard professional treatment protocols, evidence-based guidelines, Medical, and NJM Policies and Procedures.
- When insufficient documentation exists, contact appropriate parties and obtain necessary medical documentation to review and ensure the drugs prescribed are clinically efficacious, medically necessary, and the dosage and duration are appropriate.
- Refer requests that meet established criteria for peer review, fail to demonstrate medical necessity, or present high complexity for physician review and determination.
- Monitor physician prescribing patterns, medical documentation and UDT practices to ensure compliance with NJM, WC and state requirements.
- Recognize cases/requests/issues that require consultation with medical, claims, legal staff in order to determine the best approach.
- Perform patient and/or provider education and outreach, as required (written and/or telephonic).
- Identify and report medical quality events, as required under the Quality Improvements Program.
- Concisely and accurately document all reviews and determinations in claims management system as required. Ensure that any guidelines and documentation used to make determination or to refer for peer physician review are referenced.
- Understand, apply, and comply with all statutory, regulatory, licensing requirements, and NJM policies/guidelines that affect nurse case management and medical management work.
- Stay abreast of industry news and trends. Proactively seeks opportunities to increase knowledge on topics that impact property and casualty industry and medical community.
- Support development and implementation of pharmacy program initiatives.
- Participate and support projects around medical management initiatives.
- Identify and/or support company and departmental business process improvements.
- Actively licensed registered nurse in New Jersey and Connecticut, Delaware, Maryland, New York or Pennsylvania.
- 1-3 years nursing experience in Managed Care Setting.
- Strong decision-making skills.
- Strong relationship management skills, including the ability to develop a rapport with internal and external partners. Compassionate and empathetic. Demonstrated ability to influence others to gain buy-in and drive quality and evidence-based care.
- Collaborative and able to work well with teams.
- Demonstrated ability to problem-solve and resolve complex, multifaceted, and emotionally-charged situations
- Strong organizational and time management skills.
- Strong data analytic skills.
- Attention to detail.
- Ability to navigate technology and multiple systems effortlessly and readily adapt to changes, when needed.
- Intermediate Microsoft Office Suite skills (Outlook, Word, Excel, PowerPoint).
