CVS Health Prior Authorizations Representative (OHRISE) in Ohio
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. Must reside in Ohio.Fundamental Components:• 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.
• 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.• Ability to work on a rotation schedule for weekends/holidays.
COVID-19 Vaccination Requirement
CVS Health requires its Colleagues in certain positions to be fully vaccinated against COVID-19 (including any booster shots if required), where allowable under the law, unless they are approved for a reasonable accommodation based on disability, medical condition, pregnancy, or religious belief that prevents them from being vaccinated.
If you are vaccinated, you are required to have received at least one COVID-19 shot prior to your first day of employment and to provide proof of your vaccination status within the first 30 days of your employment. For the two COVID-19 shot regimen, you will be required to provide proof of your second COVID-19 shot within the first 60 days of your employment. Failure to provide timely proof of your COVID-19 vaccination status will result in the termination of your employment with CVS Health.
If you are unable to be fully vaccinated due to disability, medical condition, pregnancy, or religious belief, you will be required to apply for a reasonable accommodation within the first 30 days of your employment in order to remain employed with CVS Health. As a part of this process, you will be required to provide information or documentation about the reason you cannot be vaccinated. If your request for an accommodation is not approved, then your employment may be terminated.
Medicaid or managed care experience is a plus.
High School Diploma or G.E.D.
At Aetna, a CVS Health company, we are joined in a common purpose: helping people on their path to better health. We are working to transform health care through innovations that make quality care more accessible, easier to use, less expensive and patient-focused. Working together and organizing around the individual, we are pioneering a new approach to total health that puts people at the heart.
We are committed to maintaining a diverse and inclusive workplace. CVS Health is an equal opportunity and affirmative action employer. We do not discriminate in recruiting, hiring or promotion based on race, ethnicity, gender, gender identity, age, disability or protected veteran status. 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.
- CVS Health Jobs