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Candidates MUST HAVE AT LEAST TWO YEARS OF prior authorization experience.

Schedule: For training there is a set schedule 8am-430pm CST Monday-Friday. Following training, you will have a permanent schedule. Shift range varies and is subject to change. Will work 5 days concurrently to include either a Saturday or Sunday.

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

Position Summary

Collection of appropriate clinical/medical data needed to perform clinical assessments and/or reviews as per the health plan/employer agreed criteria, including inbound from the coordinator as needed as well as outreach calls to physician offices.

-Conducts prospective, concurrent, and/or retrospective review of cases using health plan/employer agreed upon

-Documentation of required clinical/ medical data that support case decision as required – electronically and/or in written format.

-Coordinates timely communication of case decision to physician, health plan/employer, patient and other healthcare professionals, and internal departments within CVS\Caremark following agreed upon approval & denial management processes.

-Generate, review, and validate reporting related of program results

-Participate in implementation of new Specialty Pharmacy Programs with employers and health plans as needed.

-Documentation and validation of client specific processes including communication procedures plan demographics, criteria selection, denial management procedures, and reporting requirements.

-Facilitation of documentation of program agreement with client.

• Review complex clinical criteria-based prior authorizations in accordance with CVS/Caremark policies and procedures.

• 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 bases, 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.

• Working hours will vary. Shift range include Sunday – Saturday 8:00 AM – 6:00 PM CST. New hires will be expected to work a weekend shift ongoing as part of their permanent schedule rotation (Sunday-Thursday or Tuesday-Saturday).

• 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 computer screens, and keyboarding.

• Must have regular and predictable attendance.

• Colleague will be required to work business required overtime/ work weekends when business requires, making outreach, and processing prior authorization requests.

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, 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.

Pay Range

The typical pay range for this role is:

$22.40 - $48.67

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 Benefits | CVS Health

We anticipate the application window for this opening will close on: 01/15/2025

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