Prior Authorization Clinical Reviewer

We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time.

Position Summary

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 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.

Required Qualifications

• 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.

Preferred Qualifications

• Previous experience in utilization management.
• Previous experience in both medical and behavioral health fields.
• Previous experience in acute care.
• Strong critical thinking and written communication skills.
• Ability to operate independently.

Education

• Associate’s degree in Nursing.

Anticipated Weekly Hours

Time Type

Pay Range

The typical pay range for this role is:

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. 
 

Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong.

Great benefits for great people

We take pride in offering a comprehensive and competitive mix of pay and benefits that reflects our commitment to our colleagues and their families.

Additional details about available benefits are provided during the application process and on Benefits Moments.

Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.