Specialty Biologic Clinical Review RN

Caring. Connecting. Growing Together.

Optum is a global organization that delivers care, aided by technology to help millions of people live healthier lives. The work you do with our team will directly improve health outcomes by connecting people with the care, pharmacy benefits, data and resources they need to feel their best. Here, you will find a culture guided by inclusion, talented peers, comprehensive benefits and career development opportunities. Come make an impact on the communities we serve as you help us advance health optimization on a global scale.

The Specialty Biologics Clinical Reviewer is responsible for managing high-risk patient population(s) to streamline patient access to therapy and facilitate communication between FlexCare, the referring provider's office, and the patient. They are also responsible for monitoring and leading the intake department in accordance with the key business initiatives and growth. This position is hands-on and will be responsible for oversight of all intake functions, as well as communication with internal and external resources.

This is a full-time position with typical working hours of Monday through Friday, 8:00 a.m. to 5:00 p.m. Hours and work shifts may change in accordance with business needs. Exempt employees must have the ability to be on-call and available, as business needs required.

You'll enjoy the flexibility to work remotely * from anywhere within the U.S. as you take on some tough challenges.

Primary Responsibilities:

To perform this job successfully, an individual must be able to perform each essential duty listed below satisfactorily. Reasonable accommodation may be made to enable qualified individuals with disabilities to perform essential functions.

• Serves as the clinical expert on a subset of high-risk and/or high-volume specialty medications.
• Serves as a drug specific liaison and facilities ongoing communication regarding their active patient's education as needed.
• Tracks patients from initial notification of referral, through the intake process and throughout their course of treatment to ensure all barriers to care are identified and addressed promptly.
• Completes clinical reviews to ensure the appropriateness of therapy/prescription per company protocol, Medicare, Medicaid, and commercial payers in multiple states.
• Assists the Intake department in reviewing and gathering all supporting documents to ensure prior authorization approval.
• Composes letters of medical necessity (LMNs) and appeals to advocate for patient access to therapy, as supported by provider documentation, clinical trials, and other medically supported resources.
• Collaborates with manufacturer Patient Services teams to ensure all manufacturer resources are being utilized effectively to support the patient prior to and during treatment.
• Communicates frequently with patients to ensure they are receiving optimal service and to address any reported problems with care.
• Serves as an active member of the Quality Assurance program to identify high-risk/high-volume QA initiatives.
• Works closely with Intake, Reimbursement, and Sales to identify areas of program improvement.
• Tracks and reports drug/program-specific KPIs to company leadership on a monthly basis.

You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.

Required Qualifications:

• Active unrestricted RN license in the state of employment
• 2+ years of customer service or healthcare sales experience
• Experience in the management of patients on specialty medications
• Experience composing or assisting in medical writing
• Proficient in Microsoft Suite
• Ability to travel in and out of the state up to 25% of the time

Preferred Qualifications:

• Bachelors of Nursing (BSN)
• 2+ years experience Specialty Biologic Clinical review
• Experience with prior authorizations approval process

Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. In addition to your salary, we offer benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). The salary for this role will range from $71,200 to $127,200 annually based on full-time employment. We comply with all minimum wage laws as applicable.

Application Deadline: This will be posted for a minimum of 2 business days or until a sufficient candidate pool has been collected. Job posting may come down early due to volume of applicants.