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CVS Health is a leading healthcare company operating CVS Specialty, CVS Pharmacy, CVS MinuteClinic, and CVS Caremark. In 2018, CVS combined forces with healthca
Prior Authorization Clinical Reviewer
Location
Arizona
Posted
121 days ago
Salary
$26 - $74 / hour
Seniority
Senior
Job Description
Prior Authorization Clinical Reviewer
CVS Health
• 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
Job 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
- 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
- Affordable medical plan options
- 401(k) plan (including matching company contributions)
- Employee stock purchase plan
- No-cost programs for all colleagues including wellness screenings, tobacco cessation, and weight management programs
- Confidential counseling and financial coaching
- Paid time off
- Flexible work schedules
- Family leave
- Dependent care resources
- Colleague assistance programs
- Tuition assistance
- Retiree medical access
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