We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time. Position Summary You will provide processing and communication of specialty medication prior authorization (PA) requests reviewed by the Caremark 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. • Train and mentor representatives on the PA team. Complete other PA assignments as delegated by the PA leadership team.
CVS Health/Aetna hires nurses for remote positions in health plan administration and virtual care delivery. Roles include Appeals Nurse Consultants who review clinical complaints and appeals for Medicare/Medicaid plans while ensuring regulatory compliance; Utilization Management Nurse Consultants who review services for medical necessity, coordinate discharge planning, and collaborate with providers to ensure appropriate care; and MinuteClinic Virtual Care Nurse Practitioners who provide direct patient care through a remote platform for patients 18 months and older. These positions require clinical expertise to support members in receiving safe, appropriate, and cost-effective care while meeting state and federal requirements.
