Specialty Prior Authorization - Licensed Practical Nurse

CVS Health; United States; Remote; USD 60,000 - 80,000; Full time

Job summary

CVS Health is seeking a Specialty Prior Authorization Licensed Practical Nurse to review complex clinical prior authorizations. This full-time, remote position requires prior authorization experience in a clinical setting and offers the opportunity to work with a dedicated team in an impactful healthcare setting.

Benefits

Affordable medical plans

401(k) with company matching

Employee stock purchase plan

Paid time off

Tuition assistance

Qualifications

• Active LPN/LVN license required.
• Minimum 2 years' experience in prior authorization review.
• Proficiency in computer skills and multitasking.

Responsibilities

• Review clinical criteria-based prior authorizations.
• Collaborate with healthcare professionals on prior authorizations.
• Adhere to regulatory compliance and quality assurance activities.

Skills

Communication

Multitasking

Problem Solving

Education

Licensed Practical Nurse (LPN) License

Tools

MS Office

Telephony Programs

Job description

Specialty Prior Authorization - Licensed Practical Nurse

At CVS Health, we’re building a world of health around every consumer and surrounding ourselves with dedicated colleagues who are passionate about transforming health care.

As the nation’s leading health solutions company, we reach millions of Americans through our local presence, digital channels and more than 300,000 purpose-driven colleagues – caring for people where, when and how they choose in a way that is uniquely more connected, more convenient and more compassionate. And we do it all with heart, each and every day.

Please do not apply if you do not have 2 years of Prior Authorization experience.

This is a full-time remote position for candidates who have Prior Authorization Experience in MDO, PMB, or in a Clinical Setting

Schedule: There is a set schedule for initial training from 8am-4:30pm CST Monday-Friday.

Following training, colleagues will have a permanent schedule but the shift range will vary and is subject to change .

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

Position Summary:

• Review complex clinical criteria-based prior authorizations (electronically and/or in written format) in accordance with CVS/Caremark policies and procedures and per the health plan/employer agreed criteria.

• 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 basis, 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.

• 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 programs on 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.

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 Nursing, 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.

Anticipated Weekly Hours

40

At CVS Health, we’re building a world of health around every consumer and surrounding ourselves with dedicated colleagues who are passionate about transforming health care.

As the nation’s leading health solutions company, we reach millions of Americans through our local presence, digital channels and more than 300,000 purpose-driven colleagues – caring for people where, when and how they choose in a way that is uniquely more connected, more convenient and more compassionate. And we do it all with heart, each and every day.

Please do not apply if you do not have 2 years of Prior Authorization experience.

This is a full-time remote position for candidates who have Prior Authorization Experience in MDO, PMB, or in a Clinical Setting

Schedule: There is a set schedule for initial training from 8am-4:30pm CST Monday-Friday.

Following training, colleagues will have a permanent schedule but the shift range will vary and is subject to change .

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

Position Summary:

• Review complex clinical criteria-based prior authorizations (electronically and/or in written format) in accordance with CVS/Caremark policies and procedures and per the health plan/employer agreed criteria.

• 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 basis, 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.

• 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 programs on 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.

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 Nursing, 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.

Anticipated Weekly Hours

40

Time Type

Full time

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.

Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong.

Great benefits for great people

We take pride in our comprehensive and competitive mix of pay and benefits – investing in the physical, emotional and financial wellness of our colleagues and their families to help them be the healthiest they can be. In addition to our competitive wages, our great benefits include:

• Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan.

• No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching.

• Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility.

For more information, visit https://jobs.cvshealth.com/us/en/benefits

We anticipate the application window for this opening will close on: 04/27/2025

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

About the company

At CVS Health, we share a clear purpose: helping people on their path to better health. Through our health services, plans and community pharmacists, we’re pioneering a bold new approach to total health. Making quality care more affordable, accessible, simple and seamless, to not only help people get well, but help them stay well in body, mind and spirit.

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