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Position Summary

This position is a 100% remote, work from home in the USA opportunity and will not be patient facing.

You will provide processing and communication of Specialty medication prior authorization (PA) referrals reviewed by the Case Review Unit (CRU) for the Specialty Guideline Management Programs for the Pharmacy and Medical benefits. Reporting to the Pharmacy Operations Manager, working with physician office staff and customer service, admissions. and pharmacy operations departments to communicate referral status. You will also oversee fax processing and providing telephone call assistance for prescriber office staff, pharmacies and members based on program criteria. Responsibilities include answering inbound phone calls, processing cases, loading authorizations, and making follow-up phone calls. Maintaining complete and accurate, documentation of all necessary information is necessary and will involve computer system data entry, data management, and reporting. Review complex clinical criteria-based prior authorizations in accordance with CVS/Caremark policies and procedures.

• 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.

Required Qualifications

• 2 years of clinical experience as a LPN/LVN.

• 1+ years of prior authorization experience in an MDO or a clinical setting

• A LVN (Licensed Vocational Nurse) or LPN (Licensed Practical Nurse) that must hold an unrestricted license in state of residence

• Must be willing and able to work 8 hour shift Sunday through Saturday, between 8am and 8pm in time zone of residence

• Must be willing and able to work occasional weekends per business needs

Preferred Qualifications

• 3+ years prior related clinical work experience

• Experience using MS Office and other Windows-based computer applications and phone use.

• Digital charting

• Managed care or health plan previous experience,

• Call center experience

• Multi-tasking experience

• Prior remote experience

• Case Management experience

• High production experience

Education

LVN/LPN Diploma required

Associate's degree in nursing as LPN/LVN preferred

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 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 (https://jobs.cvshealth.com/us/en/benefits)

We anticipate the application window for this opening will close on: 10/02/2024

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

We are an equal opportunity and affirmative action employer. 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.