Prior Authorization Clinical Reviewer

CVS Health

1d • $26 - $75

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 Mercy Care is a not-for-profit Medicaid managed-care health plan, serving Arizonans since 1985. We provide access to physical and behavioral health care services, to people who are eligible for Medicaid. Our members include families, children, seniors, and individuals who have developmental/cognitive disabilities. We hold multiple contracts with AHCCCS, Arizona’s Medicaid agency, and deliver services throughout the state. Mercy Care is administered by Aetna, a CVS Health company. Our staff is employed by Aetna and CVS Health. This gives Mercy Care the resources of a national organization, and still allows us to bring our members the familiarity and presence of a local team of people who put our members at the center of everything we do. 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.
• 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.

Benefits

• Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan.
• No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching.
• Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Associate degree