Utilization Management RN - Specialty Pharmacy

Join the Cleveland Clinic team, where you will work alongside passionate caregivers and provide patient-first healthcare. Cleveland Clinic is recognized as one of the top hospitals in the nation. At Cleveland Clinic, you will receive endless support and appreciation and build a rewarding career with one of the most respected healthcare organizations in the world.   

As a Utilization Management RN, you will provide a high level of patient care and clinical support to individuals enrolled in the Specialty Pharmacy Patient Management Program. Your responsibilities will include coordinating and obtaining prior authorizations for medication coverage, managing appeals, reviewing patient charts, conducting follow-up assessments to monitor adherence and side effects, providing patient counseling and offering injection training as needed. You may also contribute to the development and implementation of special projects under the direction of the Manager.

A caregiver in this role works remote in Ohio, rotating day shifts between 7:00 a.m. – 6:00 p.m.

A caregiver who excels in this role will:

• Provide prior authorization support for Specialty medications specific to disease state as assigned.

• Prioritize and organize work to meet changing priorities.

• Utilize analytical ability required to gather data and use clinical judgment to apply predetermined criteria or use independent clinical judgment when no predetermined criteria exist to identify problems and facilitate resolution.

• Use independent clinical judgment in reviewing records to determine appropriate off label use of specialty medication. If proper procedures have been followed, appropriate escalation of PA denials through the appeals process.

• Make recommendations regarding appropriateness of the treatment plan specific to the nurse’s assigned disease state.

• Contact Physician’s office regarding questions, concerns or problems with the prescription before providing authorization support to other groups so that errors or discrepancies are corrected early in the workflow, making the process more efficient for other groups.

• Complete prior authorizations for assigned patients with a minimum as deemed appropriate by Manager.

• Apply clinical studies or guidelines accurately to monitor appropriateness of medications specific to each disease state.

• Follow department guidelines on escalation processes and refer cases appropriately to pharmacists, teams and managers.

• Maintain professional work standards including confidentiality, ethical principles and professional work habits.

• Maintain and support collaborative relationships with Physicians and the multidisciplinary team.

• Document appropriately in Epic Specialty Encounter notes to provide evidence that the Prior Authorization process for the case was followed.

• Attend all staff meetings when scheduled to work.

Minimum qualifications for the ideal future caregiver include:

• Graduate of an accredited school of nursing with licensure as a Registered Nurse (RN) in the State of Ohio

• Current valid license in the State of Ohio as a Registered Nurse (RN)

• Three years equivalent full-time clinical experience as a Registered Nurse

• Knowledge of medical terminology, anatomy and physiology, diagnosis, surgical procedures and basic disease processes

• Analytical ability required to gather data, decide on conformity based on predetermined criteria, identify problems and refer for resolution

• Proficient with Microsoft Office and Epic

• Knowledge of prescription benefit and prior authorization requirements for specialty medications, adequacy of documentation, and ability to conduct research of issue at hand, as well as formulate recommendations based on findings; capable of providing in-service education to health care providers on this topic

• Knowledge of licensing and accreditation standards

Preferred qualifications for the ideal future caregiver include:

• Bachelor of Science in Nursing

• Prior Utilization Management experience

• Experience in Oncology

Our caregivers continue to create the best outcomes for our patients across each of our facilities. Click the link and see how we’re dedicated to providing what matters most to you: https://jobs.clevelandclinic.org/benefits-2/

Physical Requirements:

• Requires walking, sitting, and/or standing for long periods of time.

• Requires constant attention to detail, reading of medical records, and meeting deadlines.

• Works in an environment where there is some discomfort due to dust, noise, temperature.

Personal Protective Equipment:

• Follows standard precautions using personal protective equipment as required

Pay Range

Salaries [which may be] shown on independent job search websites reflect various market averages and do not represent information obtained directly from The Cleveland Clinic. Because we value each individual candidate, we invite and encourage each candidate to discuss salary/hourly specifics during the application and hiring process.