Utilization Management Nurse

Valeris is an integrated life sciences commercialization partner that provides comprehensive solutions that span the entire healthcare value chain. Backed by proven industry expertise and results-driven technology, Valeris helps navigate the complex life sciences marketplace by providing commercialization solutions to accelerate value and enhance patient lives.

Valeris fosters a culture that encourages individuality and provides opportunities for creativity, growth, and success while fostering a team environment. We are a diversity-driven organization with an inclusive approach to delivering patient-centric solutions that, eliminate barriers for patients, and increase patient access to life altering medications.

Utilization Management Nurse will facilitate a collaborative process with key stakeholders to provide recommendations for denied PA.  These services will include:

• Review of every PA and appeal denial received by the HUB
• Evaluate CM (Case Manager) documentation of all PA/appeals cases in CRM (Customer Relationship Management System) to ensure payer/PBR and all PA/appeals fields are correct in each case
• Collect key denial data utilizing designated worksheet to capture insights on each denial
• Provide denial feedback to CM and FRM (Field Reimbursement Manager) including recommendations for next steps
• Review reporting against formulary coverage daily, with appropriate follow-up with the CM to ensure accurate information was provided and support next steps
• Act as a PA/appeals subject matter expert for CM and FRM
• Speak with FRM to discuss PA/appeal denied cases
• Provide detailed PA/appeal analysis with each Quarterly Business Review (QBR)

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• • Establish relationships, develop trust, and maintain rapport with nurses, case managers, healthcare providers, payers and clients in a 100% telephonic setting
  • Serve as an expert on prior authorization, denials, payer requirements with drug insurance coverage
  • Serve as an advocate to patients regarding eligibility requirements, program enrollment, reimbursement process, affordability support, and general access for prescribed therapy
  • Serve as a resource to support healthcare provider offices regarding questions, concerns or challenges with the PA Appeals/Denial process
  • Ability to understand and explain benefits offered by all payer types including private/commercial and government (i.e., Medicare, Medicaid, VA and DOD)
  • Act as an assigned liaison to client contacts (e.g., regional contact for sales representatives), program management, other internal stakeholders and healthcare providers
  • Maintain records in accordance with applicable standards and regulations to the programs/promotions
  • Provide unparalleled customer service while serving as a brand advocate and program representative; understands the importance of achieving quality outcomes and commit to the appropriate use of resources
  • Evaluate and contribute to development of program resources
  • Coordinate and utilize resources to share and secure financial options for those with financial need
  • Follow program guidelines and escalate complex cases according to program policy and procedures
  • Accurately maintain, constantly update, and successfully navigate patient account records in a digital CRM
  • Report and document adverse events and product/safety complaints as per program SOPs
  • Participate in program specific client meetings and training sessions
  • Participate in program specific orientation meetings and demonstrate clinical and program competency on written, evaluated tests
  • Maintains a high level of ethical conduct regarding confidentiality and privacy
  • Help maintain team morale by consistently demonstrating positive attitude
  • May be asked to perform related job duties that are not specifically set-forth in this job description.
  • Utilize Valeris’ values as the driving force behind the team’s success
  • On time adherence to training deadlines for all corporate policies and procedures
  • Ensure all SOPs are followed with consistency
  • Perform additional tasks or projects as assigned

• AD or Bachelor’s Degree in Nursing (BSN, RN) with a valid nursing license in one or more states
• Four or more years of nursing experience; prior telephonic experience a plus
• Knowledge of medical insurance terminology and reimbursement/insurance, healthcare billing, physician office, health insurance processing or related reimbursement experience a plus
• Ability to communicate clearly and effectively orally and in writing-may be asked to submit a written test sample
• Proficient with Microsoft products
• Experience and comfort with a digital CRM required
• Attention to detail and committed to following through in communication with team members, healthcare providers and clients
• Empathetic listening skills in order to interact effectively with team members, healthcare providers and clients
• Willingness to work in a fast-paced environment and have the ability to multi-task and pivot with ease
• Strong customer service experience and skills