The Nurse Clinician - RN is responsible for reviewing escalated clinical criteria reviews for providers, members and patient client advocates within the Prior Authorization/Utilization Management department. Identify and track trends for analytics reporting to ensure clinical criteria program integrity. Maintain a professional and ethical behavior at all times as outlined by the Nurse Practice Act and applicable company policies.
To provide quality clinical criteria review for escalated Prior Authorizations as defined by Client specifications to ensure patients are serviced accurately and timely. Identifies and supports necessary updates or changes to existing clinical assessments.
- Previous clinical criteria review experience preferred; Active professional affiliations and/or national certification in related clinical specialty preferred;
- Able to work flexible work schedule.
- Perform escalated clinical review and analysis of clinical program descriptions for clinical and criteria integrity.
- Maintains contact database and responds to member and physician inquiries regarding clinical programs. Makes recommendations regarding escalation of issues, and follows through with escalation process.
- Acts as liaison between clients, patients and patient care advocates to provide guidance on clinical criteria.
- Performs initial clinical review and analysis of prior authorization cases based on state regulations.
- Special projects/assignments as needed.
- Bachelor's Degree - Other: Nursing
- 2 - 5 Years of Relevant Work Experience
ABOUT THE DEPARTMENT
United BioSource Corporation (UBC), a subsidiary of Express Scripts, is a leading provider of pharmaceutical support services, partnering with life science companies to make medicine and medical products safer and more accessible. Our services support the full lifecycle of medicine and medical products, including development, commercialization, and long-term value and safety.
While UBC offers employment within Patient Support, Nursing, Pharmacy and Corporate, two main focus areas for the company are Clinical Development & Research and Safety & Risk Management. Members of the Clinical Development and Research teams help evaluate study protocol, target study population, recruit physicians and patients, and collect, clean, validate and report data. As a result, sponsors are able to submit findings to regulatory authorities or make a no-go decision in a timely and clear-cut manner. Additionally, our Safety and Risk Management teams develop, deliver, and report evidence to reinforce safe and appropriate product use.
Through our Patient Access services, we help patients begin therapy quickly and remain on therapy, building strong relationships with patients to ensure optimal care.
UBC aligns with Accredo and CuraScript SD, also part of the Express Scripts family, to provide best-in-class, integrated services.
ABOUT EXPRESS SCRIPTS
Advance your career with the company that makes it easier for people to choose better health.
Express Scripts is a leading healthcare company serving tens of millions of consumers. We are looking for individuals who are passionate, creative and committed to creating systems and service solutions that promote better health outcomes.
Join the company that Fortune magazine ranked as one of the 'Most Admired Companies' in the pharmacy category. Then, use your intelligence, creativity, integrity and hard work to help us enhance our products and services.
We offer a highly competitive base salary and a comprehensive benefits program, including medical, prescription drug, dental, vision, 401(k) with company match, life insurance, paid time off, tuition assistance and an employee stock purchase plan.
Express Scripts is committed to hiring and retaining a diverse workforce. We are an Equal Opportunity Employer, making decisions without regard to race, color, religion, sex, national origin, age, veteran status, disability, or any other protected class. Applicants must be able to pass a drug test and background investigation.
Express Scripts is a VEVRAA Federal Contractor.
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