the calls are routed to us nurse for patients that have known chronic

The calls are routed to us nurse for patients that

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the calls are routed to us nurse for patients that have known chronic conditions or multiple conditions. We are trained in all areas as a customer service agent, but we are also nurse, the purpose behind this is so that we can receive these calls and answer the patient’s questions that caused them to call their insurance plan. While answering the patient’s original question we listen as clinicians as well so that we can then also provide clinical information, education, possible treatment options, review medication and so much more. Our main goal in this position is to make sure that the patient has all the needed information, and resources to help them better manage their conditions. We make necessary calls to provider’s office for instance if a medication was denied, and it could be as easy as making sure that a prior authorization is submitted to the right department or as complicated as making sure the provider’s office knows how to send in an appeal with the right medical information to try to have the medication covered. There is so much involved and at the end we make sure that everything that can be donefor the patient is achieved even if it means setting up commitments to work on the issue with other departments. All in order to make sure that the patient gets the needed treatment. Something that comes to mind for me was a recent patient that had called in needing helpwith a prior authorization. The patient had been waiting for approval from the insurance company for a bone marrow exam/lab test, the to rule out osteosarcoma. The patient was obviously scared and nervous, she had been waiting for a week before calling since she hadn’t heard anything from either the insurance or her doctor’s office. The provider’s office had told her that they had submitted the information to the insurance company but hadn’t heard back. I looked in our internal system but could not find any information on file that we had received a prior authorization. I reached out to our clinical department, to see if they had received anything
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Running head: Professional Roles and Values9recent since they are the ones to process the prior authorizations. They confirmed that they didn’thave anything on file either on their end. At that point I had to reach out to the provider to informthem how to send out the prior authorization and to make sure that it was marked as an urgent request in order to have it expedited. I gave the member the information and turnaround time for the authorization and that it would take 3 business days to process so that helped to ease her mind on not having to wait that long for the exam. After all of that I also got her in touch with a case manager from the insurance side in order to help with coordination between the provider and the insurance company; that way she could have assistance through the whole process and prevent any further complications with her treatment.
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