Responsible to review incoming point-of-sale prescription authorization requests; assess and apply evidence-based treatment and jurisdictional guidelines to drug approval process to ensure best practice standards. Develop action plan, effectively communicate with business partners, and facilitate referrals to leverage pharmacy interventions as appropriate. Responsible for pharmacy assessment , interventions and recommendations at any time in the life of the claim. Provides consultation to Claims Team.

Responsibilities:

• Assessment of complete medication regimen prescribed against established guidelines
• Working knowledge of Managed Care tools to utilize the right expert for pharmacy intervention
• Proficiency in Pharmacy tools as available through PBM to maximize utilization of program and achieve optimum outcomes
• Monitor prescription regimens on identified claims to ensure dosage and duration do not exceed what is medically reasonable and necessary according to FDA guidelines, treatment guidelines, manufacturing guidelines or weaning treatment plans as established
• Assessment of pharmacy utilization for relatedness, cost appropriateness and safety. Facilitate recommendations as appropriate
• Facilitate Peer Review, Urine Drug Screen,Drug Utilization Review (Drug UR) or to obtain expert recommendations on therapeutic alternatives and weaning plans for current medication protocols, appropriateness per guidelines and jurisdictional requirements
• Apply state Medical Treatment Guidelines relating to pharmacy parameters to maximize jurisdictional opportunity to manage medication use
• Maintain a strong working knowledge of evidence-based treatment protocols for daily assessment activities
• Demonstrate commitment to Company's Code of Business Conduct and Ethics, and apply knowledge of compliance policies and procedures, standards and laws applicable to job responsibilities in the performance of work

• Registered Nurse (RN) license or Licensed Practical Nurse (LPN) required with 5 + years clinical background in pain management, addictions, clinical rehabilitation, pharmacy management, utilization review, medical-surgical, orthopedics, or ER/ICU/CCU nursing
• Compact nurse license preferred
• Develops case action plans for complex claims and offers realistic recommendations for moving the claim forward. Facilitates recommendations as appropriate.
• Expert knowledge and utilization of evidenced based treatment guidelines to establish appropriate medical treatment
• Maintains current knowledge of, and complies with, all regulatory requirements for assigned jurisdictions related to workers' compensation medical management
• Strong verbal and written communication skills with internal and external customers, vendors, and provider
• Provides a high degree of customer service to clients, including participation in claims reviews, stewardship meetings and similar account-specific meetings
• Analysis/Judgment: Demonstrates critical thinking skills with sound analysis, judgment and decision making with a focus on attention to detail
• Planning and Organizing: Demonstrates strong organizational skills with the ability to analyze and balance workload requirements
• Teamwork: Demonstrates personal interaction skills showing consideration for others and awareness of the effects of one's own behavior. Proactively contributes to the organization's service delivery and profitability
• Collaboration: Works effectively with others to achieve specific goals in order to achieve overall success of assigned projects
• Demonstrates computer literacy in the use of email, MS Office Product Suite (i.e. Word, Excel), proprietary PMA systems and internet queries for research
• Maintains current RN/LPN licenses and certifications, as necessary. Ensures that all state-required Continuing Education Credits are obtained as needed to maintain license
• Certified Case Manager (CCM); or obtain certification one year from hire. Other professional certifications considered on an individual basis