Prior Authorization Clinical Reviewer

CVS Health•Work At Home-Arizona, MS

1d•$26 - $75•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. This position involves: Prior authorization review of physical and behavioral health related services. Utilization of clinical skills to coordinate, document, and communicate all aspects of the utilization/benefit management program. Application of critical thinking and knowledge of clinically appropriate treatment, evidence-based care, and medical necessity criteria for appropriate utilization of services for members with disabilities and special healthcare needs. Taking provider calls related to prior authorization questions and making calls to members to inform of the coverage determination. Gathering clinical information and applying appropriate medical necessity criteria/guideline, policy, procedure, and clinical judgment, in order to render coverage determination/recommendation/discharge planning along the continuum of care. Utilization of clinical experience and skills in a collaborative process to evaluate and facilitate appropriate healthcare services/benefits for members. Identification of members who may benefit from care management programs and facilitation of the referral. Identification of opportunities to promote quality effectiveness of healthcare services and benefit utilization. Sedentary work involving periods of sitting, talking, and listening. Performing other duties as assigned.

Requirements

5+ years of clinical experience as RN (Registered Nurse).
Ability to work 8-hour shifts, 5-days per week, with rotating days (including some weekends & holidays), supporting Arizona Time Zone.
Must have an active and unrestricted RN licensure in the state of Arizona or Compact RN licensure.

Nice To Haves

Previous experience in utilization management.
Previous experience in both medical and behavioral health fields.
Previous experience in acute care.
Strong critical thinking and written communication skills.
Ability to operate independently.

Responsibilities

Prior authorization review of physical and behavioral health related services.
Coordinate, document, and communicate all aspects of the utilization/benefit management program.
Apply critical thinking and knowledge of clinically appropriate treatment, evidence-based care, and medical necessity criteria for appropriate utilization of services for members with disabilities and special healthcare needs.
Take provider calls related to prior authorization questions and make calls to members to inform of the coverage determination.
Gather clinical information and apply appropriate medical necessity criteria/guideline, policy, procedure, and clinical judgment, in order to render coverage determination/recommendation/discharge planning along the continuum of care.
Evaluate and facilitate appropriate healthcare services/benefits for members.
Identify members who may benefit from care management programs and facilitate the referral.
Identify opportunities to promote quality effectiveness of healthcare services and benefit utilization.
Perform sedentary work involving periods of sitting, talking, and listening.
Perform other duties as assigned.