Prior Authorization Clinical Reviewer

This is a fully remote position, open to applicants in Arizona.

📋 Description

• Assess prior authorizations for services related to physical and behavioral health.

• Organize, record, and communicate activities related to utilization and benefit management.

• Utilize clinical expertise, evidence-based practices, medical necessity criteria, policies, procedures, guidelines, and clinical judgment to make coverage decisions, recommendations, and discharge planning.

• Handle provider inquiries concerning prior authorization issues.

• Contact members to relay coverage decisions.

• Assess and facilitate suitable healthcare services and benefits for members.

• Recognize members who could benefit from care management programs and initiate referrals.

• Identify opportunities to enhance the quality of healthcare services and efficient benefit utilization.

• Engage in sedentary work that involves sitting, conversing, and listening.

• Carry out additional duties as required.

⛳️ Requirements

• A minimum of 5 years of clinical experience as a Registered Nurse (RN).

• Availability to work 8-hour shifts, 5 days a week, including rotating days, weekends, and holidays.

• Must be able to support the Arizona Time Zone.

• Current and unrestricted RN licensure in Arizona or a Compact RN license.

• An Associate’s degree in Nursing.

• Prior experience in utilization management is preferred.

• Experience in both medical and behavioral health fields is preferred.

• Background in acute care is preferred.

• Strong critical thinking and written communication skills are preferred.

• Ability to work independently is preferred.

🏝️ Benefits

• Medical coverage.

• Dental coverage.

• Vision coverage.

• Paid time off.

• Retirement savings options.

• Wellness programs.

• Additional resources supporting physical, emotional, and financial well-being.

• Eligibility for CVS Health bonus, commission, or short-term incentive programs.