Prior Authorization Specialist - Contract
PhiloSalary not specified
[Remote] Manager, Prior Authorization UM - Aetna Medicaid Texas - RN at CVS Health
United States
Not SpecifiedCompensation
N/AExperience Level
N/AJob Type
Not SpecifiedVisa
N/AIndustries
Requirements
- Registered Nurse (RN) with an active and unrestricted license in state of residence
- 5+ years of experience in prior authorization, utilization management, or related healthcare operations
- 3-5 years leadership experience
- Strong knowledge of payer requirements, medical terminology, and healthcare coding (ICD-10, CPT)
- Excellent communication, leadership, and problem-solving skills
- Proficiency in EMR systems and authorization platforms
- Knowledge of the regulations, standards, and policies which relate to medical management
- Demonstrated ability to manage workload and meet deadlines
- Ability to cover weekends at supervisory capacity
- Registered Nurse, BSN preferred
Responsibilities
- Lead and manage the prior authorization team, including hiring, training, scheduling, and performance evaluations
- Ensure timely review and processing of prior authorization requests for medical services, procedures, and medications
- Monitor productivity and quality metrics; implement process improvements to enhance efficiency and accuracy
- Serve as a liaison between providers, payers, and internal departments to resolve authorization issues
- Stay current with payer policies, regulatory changes, and industry best practices
- Develop and maintain standard operating procedures (SOPs) for prior authorization workflows
- Collaborate with clinical leadership to ensure alignment with care delivery goals
- Manage escalations related to denied authorizations
- Prepare reports and dashboards for leadership on authorization trends, turnaround times, and team performance
Skills
CVS Health
Comprehensive pharmacy and healthcare services
About CVS Health
CVS Health operates a large network of retail pharmacies and walk-in medical clinics across the United States, providing a variety of health-related products and services. Their offerings include prescription medications, over-the-counter health products, and beauty items, as well as pharmacy benefits management and specialty pharmacy services. CVS Health's integrated business model allows them to serve individual consumers, businesses, and communities effectively, with a focus on improving health outcomes and reducing healthcare costs. Unlike many competitors, CVS Health combines pharmacy services with medical care, making it easier for patients to access quality healthcare. The company's goal is to enhance access to healthcare and support individuals in achieving better health.
Woonsocket, Rhode IslandHeadquarters
1963Year Founded
DEBTCompany Stage
Healthcare, Consumer GoodsIndustries
10,001+Employees