Manager, Clinical Health Services, UM Prior Authorization - Aetna Medicaid

CVS Health

1d•Remote

About The Position

We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time. Position Summary The Manager of Prior Authorization is responsible for leading the daily operations of the prior authorization team supporting Virginia Medicaid. This role ensures timely, accurate, and compliant processing of authorization requests in alignment with federal and state regulations, payer requirements, and organizational standards. The Manager provides leadership oversight of clinical and operational staff, drives performance excellence, and partners with cross-functional teams to support appropriate utilization, member access to care, and high-quality outcomes. This role also plays a critical part in ensuring regulatory compliance, audit readiness, and continuous process improvement across authorization workflows. This role offers an opportunity to lead high-impact utilization management operations within a Medicaid environment, supporting access to care for vulnerable populations while ensuring compliance, quality, and operational excellence. This is a fully remote position. Eligible candidates may live anywhere in the contiguous United States.

Requirements

Active, unrestricted Registered Nurse (RN) license
Minimum of 5 years of clinical experience
Minimum of 3–5 years of utilization management, prior authorization, or managed care experience
Minimum of 3 years of leadership experience, including direct supervision of clinical or operational staff
Strong knowledge of Medicaid programs, payer requirements, and medical necessity criteria (e.g., MCG, InterQual, or equivalent)
Demonstrated experience with regulatory compliance, including federal and state Medicaid requirements and accreditation standards
Proficiency in healthcare coding (ICD-10, CPT) and authorization platforms or EMR systems
Strong analytical, organizational, and problem-solving skills with the ability to manage multiple priorities and meet deadlines
Excellent communication and interpersonal skills, with the ability to collaborate effectively across team

Nice To Haves

Experience with Virginia Medicaid programs and DMAS policies
Familiarity with accreditation standards and audit processes
Experience supporting quality improvement initiatives, including audit calibration or interrater reliability programs
Advanced knowledge of utilization management operations within a managed care organization
Master’s degree in nursing, healthcare administration, or a related field preferred
Equivalent combination of education and relevant experience will be considered

Responsibilities

Lead and manage the prior authorization team, including hiring, training, scheduling, and performance evaluations.
Ensure timely review and processing of prior authorization requests for medical services, procedures, and medications.
Monitor productivity and quality metrics; implement process improvements to enhance efficiency and accuracy.
Serve as a liaison between providers, payers, and internal departments to resolve authorization issues.
Stay current with payer policies, regulatory changes, and industry best practices.
Develop and maintain standard operating procedures (SOPs) for prior authorization workflows.
Collaborate with clinical leadership to ensure alignment with care delivery goals.
Manage escalations related to denied authorizations.
Prepare reports and dashboards for leadership on authorization trends, turnaround times, and team performance.