Job Title 

Clinical Utilization Nurse

Location

CSI Plano TX

Employee Type

Employee

Working Hours Per Week

40

At CSI Pharmacy (CSI), we are on a mission to provide Specialty Pharmacy services to patients with chronic and rare illnesses in need of complex care.
 

CSI is a rapidly growing national Specialty Pharmacy. Whether you work directly with patients or behind the scenes in support of the business and its employees, you will use your expertise, experience, and skills to support our patients and our mission. 

Summary

The Clinical Utilization Nurse (CUN) is responsible for reviewing patient referrals/information to determine if diagnosis and clinical documentation support the use of the prescribed products.  This clinician writes and/or reviews LMN templates to support obtaining authorization for treatment. The CUN coordinates and responds to requests for services for patients. This position communicates telephonically with sales team, prescribers, other departments, and with patients to ensure all necessary information required to support treatment with prescribed therapy is obtained. Makes admission/authorization decisions based on established policies, procedures, guidelines, and infusion experience. This position ensures that clinical reviews for prior authorizations requests are completed in a timely fashion to meet contractual requirements and are conducted using nationally recognized and evidence-based standards. This clinician also may perform an initial patient assessment and develop the initial Care Plan. The clinician leads patient monitoring efforts and outcome measures as directed by the Director, Clinical Utilization (DCU). Participates in Quality Improvement Projects, performs audits of medical records, and assists in preparation for audits and other regulatory activities as directed. They attend to the patient’s needs with utmost patience, care, compassion, and understanding.

Salary Range: $88,000 - $115,000/yr (DOE)

Schedule: Monday - Friday, 8:30am - 5:00pm; Will be fully on-site for first 90 days then will transition to working Hybrid (1 day/week on-site; 4 days/week remote)

Location: 5340 Legacy Dr., Plano, TX

Travel: Occasional travel for patient and clinical conferences across the U.S.

Essential Duties and Responsibilities

include the following. Other duties may be assigned, as necessary.

• Reviews and documents medical necessity for immune globulin, biologics, and other therapies as required for referrals.
• Maintains knowledge of insurance companies’ requirements for authorization.
• Reviews clinical documentation for supporting evidence of prescribed therapy for the patient’s diagnosis per established criteria prior to submission of authorization.
• Demonstrates a high degree of responsibility regarding accuracy and quality of work.  
• Maintains an accurate and up to date filing system for medical necessity and pertinent citations and sources by disease process and specialty in the shared company drive
• Documents current clinical data on the patient’s profile, completes the initial patient assessment and starts care plan.
• Reviews denied prior authorizations and appeals when appropriate.
• Drafts LMN (Letter of Medical Necessity)
• Drafts appeal letter, when applicable 
• Works closely with prescribers and their staff to coordinate patient care during the prior authorization process and/or appeals process
• Research requests not clearly meeting established criteria
• Reviews prior authorizations generated by the Benefits Investigation Specialist or Insurance Verification Specialists
• Utilizes Cover My Meds (CCM) to draft prior authorizations
• Collaborates with other referral teams, such as Intake, Patient Care Coordination, and pharmacy to ensure complete patient care.
• Conducts disease specific clinical assessments, as applicable
• Promotes patient's independence by establishing patient care goals; teaching patient, friends, and family to understand condition, medications, and self-care skills; answering questions
• Assures quality of care by adhering to therapeutic standards; measuring health outcomes against patient care goals and standards; making or recommending necessary adjustments; following pharmacy and infusion site philosophies and standards of care set by state board of nursing/pharmacy, state nurse/pharmcy practice act, and other governing agency regulations
• Monitors RTM an