Prior Authorization Clinical Reviewer

CVS Health

19h

About The Position

Mercy Care, a not-for-profit Medicaid managed-care health plan, has been serving Arizonans since 1985 by providing access to physical and behavioral health care services for individuals eligible for Medicaid, including families, children, seniors, and those with developmental/cognitive disabilities. Mercy Care holds multiple contracts with AHCCCS, Arizona’s Medicaid agency, and delivers services throughout the state. Administered by Aetna, a CVS Health company, Mercy Care benefits from the resources of a national organization while maintaining a local team focus on its members. This position involves the prior authorization review of physical and behavioral health related services. The role requires the utilization of clinical skills to coordinate, document, and communicate all aspects of the utilization/benefit management program. The reviewer will apply critical thinking and knowledge of clinically appropriate treatment, evidence-based care, and medical necessity criteria to ensure appropriate utilization of services for members with disabilities and special healthcare needs. Key tasks include handling provider calls regarding prior authorization questions, informing members of coverage determinations, gathering clinical information, and applying medical necessity criteria to render coverage determinations and discharge planning. The position also involves evaluating and facilitating appropriate healthcare services/benefits, identifying members for care management programs, and promoting quality effectiveness of healthcare services and benefit utilization. The work is sedentary, involving periods of sitting, talking, and listening.

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
Performing other duties as assigned