Registered Nurse, Rx Refill and Prior Authorization Specialist- Behavioral Health Navigation Center

St. Luke's University Health Network; Bethlehem (Northampton County); Hybrid; USD 75,000 - 95,000; Full time

Job summary

St. Luke's University Health Network in Bethlehem, PA, is seeking a Registered Nurse, Rx Refill and Prior Authorization Specialist for the Behavioral Health Navigation Center.

The hybrid role combines remote work with on-site collaboration on Broadhead Rd to deliver exceptional patient experiences through efficient medication refill and prior authorization workflows. You will mentor Rx Refill Specialists, manage prior authorization queues, liaise with providers, insurers, and practices, and

Qualifications

• Requires RN licensure in Pennsylvania and nursing degree education.
• Minimum three years of clinical experience in a pharmacy or related office.
• Experience with patient interactions over the phone is required.
• Leadership or management experience preferred; telework may be possible under policy.

Responsibilities

• Process incoming phone and electronic patient medication refills and prior authorization requests.
• Engage patients with courtesy and compassion during interactions.
• Review records and refill protocols to support appropriate refills.
• Escalate to prescribing providers when protocol criteria are not met.
• Coordinate with insurers, practices and pharmacies to address refill and authorization needs.
• Mentor Rx Refill Specialists and serve as SME for refill/ref authorization processes.

Skills

Leadership/Management

Patient communication

Pharmacy workflows

Prior authorization processes

Epic Cadence experience

Remote work readiness

Education

RN licensure in PA

Bachelor's in Nursing preferred

Tools

Epic Cadence

EHR systems

Insurance verification systems

Job description

St. Luke's is proud of the skills, experience and compassion of its employees. The employees of St. Luke's are our most valuable asset! Individually and together, our employees are dedicated to satisfying the mission of our organization which is an unwavering commitment to excellence as we care for the sick and injured; educate physicians, nurses and other health care providers; and improve access to care in the communities we serve, regardless of a patient's ability to pay for health care.

The position is hybrid between remote and Broadhead Rd.

The Registered Nurse, Rx Refill and Prior Authorization Specialist- Behavioral Health Navigation Center is responsible for successfully delivering an exceptional patient experience and ensuring patients receive proper prescription refill services. This role will work with the Rx Refill team as an escalation contact for medication refill work queues and medication prior authorization requests. The Registered Nurse, Rx Refill Specialist is responsible for responding to refill requests, following Behavioral Health Navigation Center and pharmacy procedures in refilling medications, and escalating medication concerns and controlled substances to practices and providers. This role will also perform mentoring and support to the team of Rx Refill Specialists.

JOB DUTIES AND RESPONSIBILITIES:

• Processes incoming phone and electronic patient medication refills and prior authorization requests using electronic health record, patient engagement tools and prescription refill platforms.

• Engages patients in a polite, prompt and compassionate manner during all patient interactions.

• Reviews medical records and specialty-specific prescription refill protocols to support filling of prescription when a refill request flags for review.

• Utilizes defined escalatory workflows to notify prescribing provider of medication requests that have not met protocol criteria.

• Facilitates correspondence with patients, providers, insurance companies and pharmacies as necessary to address medical refill requests.

• Monitors prior authorization work queues WQ(s) and promptly obtains and/or reviews patient insurance information and eligibility verification required to secure prior authorizations for medications, medical procedures, or testing.

• Utilizes online, fax, and telephony pathways to obtain prior authorizations from insurance companies for prescribed medications and documents medication prior authorizations in the medical record as necessary.

• Seeks additional information and/or communicates updates to patients and providers as appropriate throughout the prior authorization process.

• Engages insurance company representatives and provides required clinical information to secure prior authorization, when necessary.

• Documents pertinent information in medical record and may notify patients of overdue visits and/or necessary screenings based on defined protocol.

• Escalates medication questions or concerns to leadership and/or designee as necessary.

• Collaboratively partners with other team members to promptly address patient requests and/or concerns that may originate in other settings (e.g., Behavioral Health Navigation Center, practice operations, etc.).

• Serves as a resource and Subject Matter Expert (SME) for other team members and internal customers, research complex issues, and works with support resources to resolve patient issues.

• Serves as an escalation point for clinical questions related to prescription refills and medication prior authorizations; completes escalated Rx refill and medication prior authorization requests.

• Collaborates with Behavioral Health Navigation Center to effectively plan, optimize staffing, flex daily staffing and monitor supply and demand to maintain service levels.

• Maintains good working relations with various practices to ensure an efficient Rx refill process.

• Helps maintain communication to the Behavioral Health Navigation Center related to medication refills, medication refill denials, medication related questions, and pharmacy communication.

• Analyzes current procedures, bringing suggestions for improvement to the attention of Sr. Director, Referral Development and Patient Access or appropriate leadership.

• Supports Rx Refill Specialists to follow medication refill protocols and external resources to verify if medications are appropriate to refill and informs providers of controlled substances refilling with multiple providers or locations.

• Other duties as assigned.

PHYSICAL AND SENSORY REQUIREMENTS:

Sitting for extended periods (up to 8 hours), continual finger use, writing, computer entry, ability to hear normal conversation, and good general near and peripheral vision are required.

EDUCATION:

Required: Graduate of an accredited nursing program. Active Registered Nurse licensure in the state of Pennsylvania. Bachelor's degree in nursing preferred.

TRAINING AND EXPERIENCE:

Minimum three years recent clinical experience in a pharmacy or related office required. Familiarity/experience with patient interactions on the telephone required. Epic Cadence experience required.Minimum of two years of leadership or management experience preferred. Ability to work from home in accordance with the Network Work from Home Policy if needed.

St. Luke's University Health Network is an Equal Opportunity Employer.