Prior Authorization Clinical Reviewer

Job not on LinkedIn

🔥 14 hours ago

🌵 Arizona – Remote

🌵 Arizona – Remote

💵 $26 - $74 / hour

⏰ Full Time

🟡 Mid-level

🟠 Senior

🔍🏥 Medical Reviewer

👻 Ghost score 0%

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CVS Health

WebsiteLinkedInAll Job Openings

10,000+ employees

Founded 1963

🏥 Healthcare

⚕️ Healthcare Insurance

🛒 Retail

Healthcare • Healthcare Insurance • Retail

CVS Health is a leading American healthcare company dedicated to improving health access and affordability. The company focuses on a comprehensive approach that includes health services, health insurance, and pharmacy benefits management. Through its subsidiaries, such as Aetna and CVS Caremark, CVS Health offers a range of services that facilitate wellness, condition management, and affordable prescription drug coverage. CVS Health operates neighborhood pharmacies, provides mail-order pharmacy services, and manages specialty medication programs, aiming to make healthcare convenient and accessible for everyone. Driven by a mission to connect people with essential care services, CVS Health is committed to fostering healthier communities and supporting the wellbeing of all individuals.

📋 Description

• Review prior authorizations for physical and behavioral health-related services • Coordinate, document, and communicate utilization and benefit management activities • Apply clinical knowledge, evidence-based care, medical necessity criteria, policies, procedures, guidelines, and clinical judgment to render coverage determinations, recommendations, and discharge planning • Take provider calls regarding prior authorization questions • Call members to communicate coverage determinations • Evaluate and facilitate appropriate healthcare services and benefits for members • Identify members who may benefit from care management programs and facilitate referrals • Identify opportunities to promote healthcare service quality and effective benefit utilization • Perform sedentary work involving sitting, talking, and listening • Perform other duties as assigned

🎯 Requirements

• 5+ years of clinical experience as an RN (Registered Nurse) • Ability to work 8-hour shifts, 5 days per week, with rotating days including some weekends and holidays • Ability to support the Arizona Time Zone • Active and unrestricted RN licensure in Arizona or Compact RN licensure • Associate’s degree in Nursing • Previous experience in utilization management preferred • Previous experience in both medical and behavioral health fields preferred • Previous experience in acute care preferred • Strong critical thinking and written communication skills preferred • Ability to operate independently preferred

🏖️ Benefits

• Medical coverage • Dental coverage • Vision coverage • Paid time off • Retirement savings options • Wellness programs • Other resources supporting physical, emotional, and financial well-being • CVS Health bonus, commission or short-term incentive program eligibility