Utilization Management - Specialty Medical Prior Authorization - LPN

The Regional Municipality of Durham; Austin (TX); Remote; USD 10,000 - 60,000; Full time

Job summary

A leading healthcare company seeks a Licensed Practical Nurse (LPN) to manage prior authorization processing for specialty medications. This remote position involves collaboration with clinical teams and requires a valid LPN license plus relevant experience. The role promises a warm and supportive environment with benefits designed for employee wellness.

Benefits

401(k) plan with company matching

Affordable medical plan options

Paid time off and flexible work schedules

Tuition assistance

Wellness screenings and support programs

Qualifications

• 2+ years of LPN/LVN clinical experience.
• Must have active LPN/LVN license.
• Ability to quickly assess and adapt to changing situations.

Responsibilities

• Process and communicate prior authorization requests.
• Maintain accurate documentation and data management.
• Provide on-call nurse availability for urgent requests.

Skills

Prior Authorization

Verbal Communication

Written Communication

Problem Solving

Team Collaboration

Education

Diploma or Certification from approved LPN/LVN program

Tools

Microsoft Teams

Job description

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.

Must have Prior Authorization experience

Will work from home office

Position Summary

You will provide processing and communication of specialty medication prior authorization (PA) requests reviewed by the Aetna Specialty Medical Prior Authorization department. Reporting to the Pharmacy Operations Manager, you will work with physician office staff and customer service, admissions and pharmacy operations departments to communicate prior authorization status. You will also oversee fax processing and provide 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 criteria-based prior authorizations following policy and procedure
• Provide on-call after hours nurse availability for urgent PA requests
• Provide internal nurse support to the PA team and member services department Refer cases not meeting clinical criteria to the Pharmacist and MD team(s).
• Shift priorities while exhibiting a high level of urgency with all calls and assignments.
• Excellent verbal and written skills.
• You will work with pharmacists, other clinical colleagues, healthcare professionals and members.
• Follow all prior authorization procedures to guarantee an accurate process on each prior authorization.
• Complete other PA assignments as delegated by the PA leadership team.

Required Qualifications

• Must have active, current and unrestricted Licensed Practical/Vocational Nurse in state of residence
• 2+ years of LPN/LVN clinical experience with experience in Prior Authorization
• 1+ years of experience using Microsoft Teams, including Word, Excel and Outlook
• Must be willing and able to work Monday through Friday, Sunday through Thursday or Tuesday through Saturday between hours of 8am to 8pm CST zone

Preferred Qualifications

• 1+ years prior work experience
• Prior work experience working prior authorizations in Novologix
• Excellent interpersonal skills
• Demonstrated problems solving ability and attention to detail
• Ability to work effectively in a team environment with great dependability
• Excellent oral and written communication skills
• Ability to quickly assess and adapt to constantly changing situations, phone and PC use
• Required to possess a high mental agility and alertness
• Ability to effectively communicate with pharmacists, other clinical colleagues, healthcare professionals and members
• Ability to effectively prioritize work while exhibiting a high level of urgency with all calls and assignments
• Ability to effectively train and mentor representatives on the PA team

Education

Diploma or Certification from approved LPN/LVN program

Anticipated Weekly Hours
40

Time Type
Full time

Pay Range

The typical pay range for this role is:

$22.40 - $48.67

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: 06/06/2025

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