NEW JOB OPENING
LICENSED PRACTICAL NURSE (LPN/ LVN) PRIOR AUTHORIZATION & APPEALS
IN Remote, USA!

Required Education:

• High school diploma or Equivalent



Required License/Certification:

• Must hold an active LPN/LVN license in the state where the candidate resides



Required Qualifications/Skills/Experience:

• Prior authorization experience in a medical office (MDO), pharmacy benefit management (PBM), or clinical setting

• Experience reviewing and processing prior authorizations using clinical criteria and supporting documentation

• Experience managing inbound and outbound calls while meeting productivity, quality, and service-level expectations

• Ability to review chart notes, claims history, and prior authorization history

• Experience navigating multiple computer systems and entering accurate case documentation

• Ability to work remotely in a dedicated, HIPAA-compliant workspace with reliable, hardwired internet



Preferred Qualifications/Skills/Experience:

• Prior appeals experience

• Experience with CoverMyMeds or similar authorization platforms

• Experience in pharmacy benefit management (PBM), specialty pharmacy



Licensed Practical Nurse (LPN) / Licensed Vocational Nurse (LVN) – Prior Authorization & Appeals Overview:

• The Licensed Practical Nurse (LPN) / Licensed Vocational Nurse (LVN) will support the processing and communication of commercial pharmacy benefit prior authorizations and appeals

• This fully remote position involves reviewing criteria-based requests, documenting case information, communicating referral statuses, and providing telephone assistance to prescriber offices, pharmacies, and members

• The successful candidate will work closely with pharmacists, clinical colleagues, healthcare professionals, and member services teams to ensure accurate and timely processing

• Responsibilities include answering inbound calls, processing cases, loading authorizations and determinations, managing fax requests, making follow-up calls, and maintaining complete and accurate documentation

• Candidates must be comfortable reviewing clinical information, navigating multiple systems simultaneously, prioritizing competing assignments, and escalating cases that do not meet clinical criteria to the appropriate pharmacist or medical team

• The role requires strong communication, critical-thinking, multitasking, and documentation skills in a fast-paced, metrics-driven environment

• Candidates must be self-directed, adaptable, and able to maintain productivity throughout their scheduled shift while working independently from a HIPAA-compliant home workspace



Job Duties:

• Manage inbound and outbound calls while maintaining productivity, quality, and service-level expectations

• Review and process prior authorization and appeals requests using clinical criteria and supporting documentation

• Review chart notes, claims history, and prior authorization history to support accurate processing and determinations

• Process cases, load authorizations and determinations, and make follow-up calls

• Provide internal nursing support to the Prior Authorization and Appeals team and member services department

• Refer cases that do not meet clinical criteria to the appropriate pharmacist and medical team

• Navigate multiple systems, tools, and communication platforms simultaneously with speed and accuracy

• Process fax requests and provide telephone assistance to prescriber offices, pharmacies, and members

• Maintain complete and accurate case documentation, data entry, data management, and reporting

• Follow prior authorization and appeals policies, procedures, clinical criteria, and internal workflows

• Communicate referral status and case updates to physician office staff, customer service, admissions, and pharmacy operations teams

• Shift priorities while maintaining urgency across calls and assignments

• Demonstrate critical thinking and problem-solving when information is unclear or incomplete

• Adapt to changing priorities, processes, and clinical criteria

• Communicate professionally with team members, pharmacists, providers, members, and leadership

• Seek clarification when necessary to ensure accuracy

• Maintain accuracy while processing high volumes of work efficiently

• Participate in quality assurance activities and apply feedback for continuous improvement

• Train and mentor representatives on the Prior Authorization and Appeals team as needed

• Complete additional assignments delegated by the Prior Authorization and Appeals leadership team

• **Only those lawfully authorized to work in the designated country associated with the position will be considered.**

• **Please note that all Position start dates and duration are estimates and may be reduced or lengthened based upon a client’s business needs and requirements.**