CVS Health Hiring for Prior Authorization Representative – OhioRISE at Ohio Full Time

• As part of the bold vision to deliver the “Next Generation” of managed care in Ohio Medicaid, Ohio RISE will help

struggling children and their families by focusing on the
individual with strong coordination and partnership among
MCOs, vendors, and ODM to support specialization in
addressing critical needs. The OhioRISE Program is
designed to provide comprehensive and highly coordinated behavioral health services for children with serious/complex behavioral health needs involved in, or at risk for involvement in, multiple child-serving systems.

This is a full-time teleworker position in Ohio.

The Prior Authorization Representative supports comprehensive coordination of medical services including intake, screening and referrals to Aetna Medical Services Programs. Promotes/supports quality effectiveness of Healthcare Services.

• Performs intake of calls from members or providers

regarding services via telephone, fax, EDI.

• Utilizes eTUMS and other Aetna system to build, research

and enter member information.

• Screens requests for appropriate referral to medical

services staff.

• Approve services that do not require a medical review in

accordance with the benefit plan.

• Performs intake of calls from members or providers

regarding services via telephone, fax, EDI.

• Utilizes eTUMS and other Aetna system to build, research

and enter member information.

• Screens requests for appropriate referral to medical

services staff.

• Approve services that do not require a medical review in

accordance with the benefit plan.

• Performs non-medical research including eligibility

verification, COB, and benefits verification.

• Maintains accurate and complete documentation of

required information that meets risk management,
regulatory, and accreditation requirements.

• Promotes communication, both internally and externally to enhance effectiveness of medical management services (e.g., claim administrators, Plan Sponsors, and third-party payers as well as member, family, and health care team members respectively). Protects the confidentiality of member information and adheres to company policies regarding confidentiality.
• Communicate with Aetna Case Managers, when

processing transactions for members active in this Program.

• Supports the administration of the precertification process in compliance with various laws and regulations, URAQ and/or NCQA standards, where applicable, while adhering to company policy and procedures.
• Places outbound calls to providers under the direction of

Medical Management Nurses to obtain clinical information
for approval of medical authorizations. Uses Aetna Systems such as QNXT, ProFAX, ProPAT, and Milliman Criteria.

• Communicates with Aetna Nurses and Medical Directors, when processing transactions for members active in this Program. Sedentary work involving significant periods of sitting, talking, hearing and keying. Work requires visual acuity to perform close inspection of written and computer generated documents as well as a PC monitor. Working environment includes typical office conditions.

Pay Range
The typical pay range for this role is:
Minimum: 17.00
Maximum: 27.90

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

jobs.CVSHealth.com/benefits

Required Qualifications

• 2-4 years’ experience as a medical assistant, office

assistant or other clinical experience.

• Effective communication, telephonic and organization

skills.

• Familiarity with basic medical terminology and concepts

used in care management.

• Strong customer service skills to coordinate service

delivery including attention to customers, sensitivity to
issues, proactive identification and resolution of issues to
promote positive outcomes for members.

• Computer literacy in order to navigate through

internal/external computer systems, including Excel and
Microsoft Word.

• Ability to effectively participate in a multi-disciplinary team including internal and external participants.

Preferred Qualifications

• Medicaid or managed care experience is a plus.

Education

• High School Diploma or G.E.D.

Business Overview
Bring your heart to CVS Health Every one of us at CVS Health shares a single, clear purpose: Bringing our heart to every moment of your health. This purpose guides our commitment to deliver enhanced human-centric health care for a rapidly changing world. Anchored in our brand — with heart at its center — our purpose sends a personal message that how we deliver our services is just as important as what we deliver. Our Heart At Work Behaviors™ support this purpose. We want everyone who works at CVS Health to feel empowered by the role they play in transforming our culture and accelerating our ability to innovate and deliver solutions to make health care more personal, convenient and affordable. We strive to promote and sustain a culture of diversity, inclusion and belonging every day. CVS Health is an affirmative action employer, and is an equal opportunity employer, as are the physician-owned businesses for which CVS Health provides management services. We do not discriminate in recruiting, hiring, promotion, or any other personnel action based on race, ethnicity, color, national origin, sex/gender, sexual orientation, gender identity or expression, religion, age, disability, protected veteran status, or any other characteristic protected by applicable federal, state, or local law. We proudly support and encourage people with military experience (active, veterans, reservists and National Guard) as well as military spouses to apply for CVS Health job opportunities.