Case Management/Prior Authorization (PA) LPN

At MCPG, we are passionate about changing the face of healthcare in Middle Tennessee and Kentucky by providing access to biomedical interventions and services for sexual health and wellness. We serve our patients with a highly skilled, competent team of clinicians, staff and volunteers who dedicate their time and expertise to see patients during convenient weekday and weekend hours. We accept insured and uninsured patients with affordable, low-cost or no cost services.

Case Management/Prior Authorization (PA) LPN

Position Summary:

The case management/prior authorization (PA) LPN is responsible for coordinating patient-centered care for individuals with complex medical and psychosocial needs. Working collaboratively with patients, families, providers, and interdisciplinary care teams, this role develops and implements individualized care plans that promote positive clinical outcomes, improve quality of life, and ensure the continuity of care across the healthcare continuum. The case management nurse serves as a patient advocate, reinforces education on treatment options and self-management strategies, identifies and addresses barriers to care, and connects patients with appropriate community resources and support services. This position plays a key role in supporting patients receiving antiretroviral therapy (ART), promoting evidenced-based practice, improving care coordination, and advancing organizational goals related to quality, patient satisfaction, and clinical outcomes. Ensures that patients receive medications promptly by making certain prior authorizations are completed timely and accurately.

Essential Duties and Responsibilities:

• Gathers information about the health status and needs of patients with complex clinical circumstances who require a coordinated plan of care through patient interviews.

• Reports abnormal findings of health status to RN or provider.

• Reinforces education to patients and their families on treatment options and self-care strategies.

• Coordinates with the patient, their health care team, and family (as needed/requested) across the continuum of care to remove barriers and promote efficient and effective use of resources.

• Facilitates appropriate follow up care and refers ART patients to the appropriate next level or site of care.

• Serves in an advocacy role on behalf of patients, families, and caregivers to ensure safe, equitable healthcare provision.

• Acts as the key information and education resource for the interdisciplinary team as related to caring and securing appropriate services for ART patients.

• Educates others in the business around ART care while advocating for the patients under their care.

• Prioritizes patient outcomes and experiences. Models best practices when interacting with patients and peers. Able to coach less experienced peers.

• Integrates evidence from multiple sources and determines if an ART practice change should occur.

• Documents the progress of prior authorizations (PA) and notifies the appropriate provider of the result.

• Investigates and mitigates any PA denials. If denied, provides the denial information to the provider so the appeal process can begin if desired.

• Communicates with insurance companies, pharmacies, providers, and health care team as needed.

• Responds to messages in Ring Central, Athena, and BWell accurately and timely.

• Maintains telephone availability during scheduled work hours and responds to calls timely and accurately.

• Documents correspondence of any kind - phone call, verbal, text, portal, email - in the appropriate place timely and accurately.

• Communicates with patients, staff, health care team, and any outside customers clearly and effectively, with empathy, integrity, and accuracy.

• The responsibilities listed above are a general overview of the position and additional duties may be assigned.

Qualifications/Skills:

• Education: Must be a Licensed Practical Nurse in the State of Tennessee with an unencumbered license to practice.

• Three years of nursing experience required. One year of case management experience preferred. Prior authorization experience strongly recommended.

• Must have a proven track record of successfully delivering treatment planning services.

• Must have experience coordinating complex clinical care.

• Must have the ability to simplify complex topics so they are able to be understood by all patients regardless of background or education.

• Must possess strong collaboration and communication skills.

• Must work effectively with physicians, staff, volunteers, patients, the public, and external agencies.

• Must be able to take initiative, make decisions, problem solve, and work independently.

• Must remain receptive to changing responsibilities as well as maintain a high level of confidentiality and privacy.

Physical and Work Environment Requirements:

• Must be able to work in a shared office, in a clinic setting, or hybrid work environment.

• Must be able to sit, stand, walk, and use standard office equipment for extended periods of time.

• Must be able to lift up to 15 pounds if needed.

• Must be able to occasionally travel for required training, conferences, organizational meetings, and other business related functions.