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Licensed Practical Nurse (LPN/LVN) - Commercial Prior Authorization

Location: 100% Remote - Work from Home, U.S.

Patient-Facing: No

Schedule: 8 hour shift within hours of 8:00 AM-8:00 PM Central Time, based on business needs and mandatory OT required

Training: 8:00 AM-4:30 PM CT, Monday-Friday

Compensation

Pay Rate: $25.98-$27.87/hour

Position Summary

The Licensed Practical Nurse (LPN) / Licensed Vocational Nurse (LVN) will support the Commercial Prior Authorization (PA) team for pharmacy benefits. This is a 100% remote, non-patient-facing, high-production role with defined productivity and quality metrics.

Reporting to the Pharmacy Operations Manager, the LPN/LVN will work closely with physician office staff, pharmacists, healthcare professionals, customer service, pharmacy operations, and members to process and communicate prior authorization requests and determinations.

Key Responsibilities

-Review criteria-based prior authorization requests in accordance with established policies and procedures.

-Process and document Commercial Pharmacy Prior Authorization cases accurately and efficiently.

-Provide clinical and operational support to the Prior Authorization and Member Services teams.

-Refer cases that do not meet established clinical criteria to the appropriate Pharmacist and/or Medical Director team.

-Process faxes, authorization requests, and related documentation.

-Load and maintain authorizations within applicable systems.

-Handle inbound and outbound calls with prescriber offices, pharmacies, healthcare providers, members, technicians, and internal teams.

-Respond to inquiries and facilitate prior authorization requests with a focus on first-call resolution when applicable.

-Make follow-up calls regarding authorization requests and case status.

-Utilize clinical knowledge to support documentation and communication of medical services and prior authorization determinations.

-Maintain complete, accurate, and timely documentation in applicable systems.

-Perform computer system data entry, data management, and reporting activities.

-Collaborate with pharmacists, nurses, healthcare professionals, and other clinical and operational colleagues.

-Shift priorities as needed while maintaining a high level of urgency and accuracy.

-Meet established productivity, quality, and performance metrics.

-Multitask effectively and adapt to a fast-paced, continuously changing environment.

-Attend required training sessions, development meetings, and team activities.

-Perform other related duties and projects as assigned by PA leadership.

Required Qualifications

Active, unrestricted LPN or LVN license in the candidate's state of residence or a valid compact license.

Minimum 2 years of clinical experience as an LPN/LVN.

Recent Prior Authorization experience, preferably involving pharmacy benefits.

Experience in managed care, health plan, payer, PBM, or utilization management environments preferred.

Experience working in a high-volume, metrics-driven healthcare environment.

Strong ability to prioritize, assess situations quickly, manage multiple tasks, and adapt to changing priorities.

Experience with Microsoft Office and Windows-based computer applications.

Ability to navigate multiple computer systems simultaneously.

Experience with digital charting and electronic clinical documentation.

Strong written and verbal communication skills.

Excellent organizational skills and strong attention to detail.

Ability to work independently in a fully remote environment.

Ability to maintain regular and predictable attendance.

Preferred Experience

1-3+ years of recent Prior Authorization experience.

Pharmacy benefit Prior Authorization experience.

Case Management experience.

Managed care or health plan experience.

PBM or utilization management experience.

Healthcare call center experience.

High-volume inbound/outbound healthcare phone experience.

High-production or metrics-driven clinical operations experience.

Previous remote/work-from-home experience.


Equal Opportunity Employer: Race, Color, Religion, Sex, Sexual Orientation, Gender Identity, National Origin, Age, Genetic Information, Disability, Protected Veteran Status, or any other legally protected group status.

At Randstad, we welcome people of all abilities and want to ensure that our hiring and interview process meets the needs of all applicants. If you require a reasonable accommodation to make your application or interview experience a great one, please contact HRsupport@randstadusa.com.

Pay offered to a successful candidate will be based on several factors including the candidate's education, work experience, work location, specific job duties, certifications, etc. In addition, Randstad offers a comprehensive benefits package, including: medical, prescription, dental, vision, AD&D, and life insurance offerings, short-term disability, and a 401K plan (all benefits are based on eligibility).

This posting is open for thirty (30) days.

It is unlawful in Massachusetts to require or administer a lie detector test as a condition of employment or continued employment. An employer who violates this law shall be subject to criminal penalties and civil liability.