Specialty Prior Authorization - Licensed Practical Nurse

At CVS Health, we’re building a world of health around every consumer and surrounding ourselves with dedicated colleagues who are passionate about transforming health care.

As the nation’s leading health solutions company, we reach millions of Americans through our local presence, digital channels and more than 300,000 purpose-driven colleagues – caring for people where, when and how they choose in a way that is uniquely more connected, more convenient and more compassionate. And we do it all with heart, each and every day.

This is a full-time remote position for candidates who have Prior Authorization Experience in MDO, PMB, or in a Clinical Setting

Schedule: There is a set schedule for initial training from 8am-4:30pm CST Monday-Friday.

Following training, colleagues will have a permanent schedule but the shift range will vary and is subject to change.

Shift range: Sunday – Saturday 8:00 AM – 6:00 PM. New colleagues will be expected to work a weekend shift as part of their permanent schedule (Sunday-Thursday or Tuesday-Saturday)

Position Summary:

 

• Review complex clinical criteria-based prior authorizations (electronically and/or in written format) in accordance with CVS/Caremark policies and procedures and per the health plan/employer agreed criteria.

• Refer prior authorization cases not meeting clinical criteria for upper-level review when appropriate.

• Must possess excellent communication skills, both written and verbal.

• Shift priorities while exhibiting a high level of urgency and responsiveness with all calls, prior authorization requests, and ADHOC assignments.

• Follow all prior authorization procedures to meet business quality standards and ensuring the operational unit is complying with regulatory requirements and accreditation standards.

• Participates in quality assurance activities on ongoing basis, including but not limited to reviewing work instructions and job aids regularly.

• Collaborate with representatives on the prior authorization team, pharmacists, clinical colleagues, healthcare professionals, clients, leaders, and team members.

• Complete other prior authorization assignments as delegated by the leadership team.

• Utilization of clinical and problem-solving skills to support the research of documentation, communication of medical services, and prior authorization determinations.

• Ability to multitask, prioritize, and effectively adapt to a fast-paced changing environment.

• This position involves sedentary work with extended periods of sitting, talking on the telephone, using multiple programs on multiple computer screens, and keyboarding.

• Must have regular and predictable attendance.

• Colleague will be required to work business required overtime/work weekends when business requires.

Required Qualifications

• Hold and maintain an active, unencumbered LPN/LVN license in the state of practice.
• Position requires proficiency with computer skills which include multitasking, navigating multiple systems, and keyboarding. Experience using MS Office, other Windows-based computer applications, web based processing and telephony programs.
• Minimum 2 years’ recent experience reviewing and processing prior authorizations against health plan criteria for a determination in a specialty/skilled clinical setting i.e., specialty medical office or Pharmacy Benefits Manager (PBM).

 

Preferred Qualifications

• 3+ years prior work experience as an LPN/LVN in a specialty medical office and/or skilled clinical setting.

Education The Licensed Practical Nurse is a graduate of a school of Practical Nursing, approved by the State Agency and/or accredited by the National League for Nursing Accrediting Commission (NLNAC) at the time the program was completed by the applicant. The LPN must have a full, active, and unrestricted license as a Licensed Practical in a State, Territory or Commonwealth of the United States or District of Columbia.

Anticipated Weekly Hours

40

Time Type

Full time

Pay Range

The typical pay range for this role is:

$21.10 - $43.78

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 inclu