Remote Prior Authorization Clinical Reviewer / RN – Arizona

CVS Health

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Job ID: R0040303
Category: Clinical Services
Address: 4500 E Cotton Ctr Blvd
Location: Phoenix, AZ

Bring your heart to CVS Health. Every one of us at CVS Health shares a single, clear purpose: Bringing our heart to every moment of your health. This purpose guides our commitment to deliver enhanced human-centric health care for a rapidly changing world. Anchored in our brand — with heart at its center — our purpose sends a personal message that how we deliver our services is just as important as what we deliver.

Our Heart At Work Behaviors™ support this purpose. We want everyone who works at CVS Health to feel empowered by the role they play in transforming our culture and accelerating our ability to innovate and deliver solutions to make health care more personal, convenient and affordable.

 

 

 

Position Summary

 

This is a full-time telework position.

 

Hours for this role are Monday – Friday 8am – 5pm Arizona time. Occasional requirement for coverage during holidays and weekend through rotation (about once every 2 months). Occasional holidays as needed. Travel only to attend occasional in-person office meetings ***

 

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 the 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 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, listening

Required Qualifications

  • 5+ years of clinical experience as RN
  • Must have active and unrestricted RN licensure in the state of Arizona
  • Must reside in MST (AZ) time zone
  • Must be willing and able to travel for in-state meetings on rare occasions. Reliable transportation required. Mileage is reimbursed per our company expense reimbursement policy

Preferred Qualifications

  • Prior Utilization Management experience
  • Strong critical thinking and written communication skills.

Education:

  • Bachelor’s Degree in Nursing required

 

 

Pay Range

The typical pay range for this role is:

 

$28.25 – $60.50

 

This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls.  The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors.  This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above.

In addition to your compensation, enjoy the rewards of an organization that puts our heart into caring for our colleagues and our communities.  The Company offers a full range of medical, dental, and vision benefits.  Eligible employees may enroll in the Company’s 401(k) retirement savings plan, and an Employee Stock Purchase Plan is also available for eligible employees.  The Company provides a fully-paid term life insurance plan to eligible employees, and short-term and long term disability benefits. CVS Health also offers numerous well-being programs, education assistance, free development courses, a CVS store discount, and discount programs with participating partners.  As for time off, Company employees enjoy Paid Time Off (“PTO”) or vacation pay, as well as paid holidays throughout the calendar year. Number of paid holidays, sick time and other time off are provided consistent with relevant state law and Company policies.  

For more detailed information on available benefits, please visit jobs.CVSHealth.com/benefits

 

 

 

CVS Health requires certain colleagues to be fully vaccinated against COVID-19 (including any booster shots if required), where allowable under the law, unless they are approved for a reasonable accommodation based on disability, medical condition, religious belief, or other legally recognized reasons that prevents them from being vaccinated.

 

You are required to have received at least one COVID-19 shot prior to your first day of employment and to provide proof of your vaccination status or apply for a reasonable accommodation within the first 10 days of your employment. Please note that in some states and roles, you may be required to provide proof of full vaccination or an approved reasonable accommodation before you can begin to actively work.

 

CVS Health is committed to recruiting, hiring, developing, advancing, and retaining individuals with disabilities. As such, we strive to provide equal access to the benefits and privileges of employment, including the provision of a reasonable accommodation to perform essential job functions. CVS Health can provide a request for a reasonable accommodation, including a qualified interpreter, written information in other formats, translation or other services through ColleagueRelations@CVSHealth.com If you have a speech or hearing disability, please call 7-1-1 to utilize Telecommunications Relay Services (TRS). We will make every effort to respond to your request within 48 business hours and do everything we can to work towards a solution.