Prior Authorization Clinical Reviewer (Arizona)

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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.