Job Title & Specialty Area: High-Cost Therapy Liaison RN
Department: Utilization Management
Location: Children's Health- Trinity Towers
Shift: Monday through Friday 8:00a to 5:00p
Job Type: Remote, but there will be an expectation to come onsite 2x a month as well as any events that will require onsite attendance
Summary:
The High Cost Therapy Liaison RN is responsible for submitting accurate and timely medication authorizations. This includes but is not limited to communication with insurance providers, manufacturers, and clinical teams to assist with managing the authorization process of high-cost drugs. Serve as a subject matter expert for high-cost therapies to provide knowledge on insurance and FDA requirements provided at CHST to clinicians and departments. This role will require a strong analytical mind and attention to detail to navigate the complex regulations surrounding drug authorization and reimbursement.
Responsibilities:
* Collaborate with various staff within the provider network and health services team to obtain prior authorization and submission of appeals for high-cost therapies.
* Provide guidance and support to patients in navigating the authorization and approval process.
* Develop and maintain relationships with pharmaceutical manufacturers to ensure timely authorization and administration of medication therapies.
* Collaborate with other healthcare teams and departments to ensure all applicable steps have occurred to administer the High-Cost Therapies.
* Stay up to date with regulations and policies related to High-Cost Therapies.
* Assistance with coordination of Peer to Peers and Appeals when indicated.
* Utilization of payor portals to identify medical policies and authorization submission requirements
* Assist with effective problem-solving or general assistance to the Medication Authorization Coordinators. Consults and communicates with staff, managers, directors, and other hospital departments as required to maintain efficient departmental operations.
* Provide education to clinicians and hospital departments on the High-Cost Therapy and the implementation of the therapy for the administering area(s).
* Collaborate with departmental leaders and research department to identify current studies in preparation for operationalizing medication within the organization.
* Provides feedback to providers on recommended medications and step-therapy according to Insurance Guidelines.
* Performs other duties as assigned.
How You'll Be Successful:
WORK EXPERIENCE
* At least 3 years acute care clinical nursing or medication management Required
* At least 2 years experience working with health insurance and reimbursement practices Required
* At least 2 years knowledge of UM and case management principles Preferred
* At least 2 years medication prior authorization experience Preferred
* Knowledge of Texas Medicaid requirements Preferred
EDUCATION
* Four-year Bachelor's degree or equivalent experience BSN Required
LICENSES AND CERTIFICATIONS
* Current license to practice professional nursing in the State of Texas Upon Hire Required
Holistic Benefits - How We'll Care for You:
• Employee portion of medical plan premiums are covered after 3 years.
• 4%-10% employee savings plan match based on tenure
• Paid Parental Leave (up to 12 weeks)
• Caregiver Leave
• Adoption and surrogacy reimbursement
