[Hiring] Prior Authorization Clinical Reviewer @CVS Health

Role Description Mercy Care is a not-for-profit Medicaid managed-care health plan, serving Arizonans since 1985. We provide access to physical and behavioral health care services to people who are eligible for Medicaid. Our members include families, children, seniors, and individuals who have developmental/cognitive disabilities. This position involves:

• Prior authorization review of physical and behavioral health related services.
• Utilization of clinical skills to coordinate, document, and communicate all aspects of the utilization/benefit management program.
• Application of critical thinking and knowledge of clinically appropriate treatment, evidence-based care, and medical necessity criteria for appropriate utilization of services for members with disabilities and special healthcare needs.
• Taking provider calls related to prior authorization questions and making calls to members to inform of the coverage determination.
• Gathering clinical information and applying appropriate medical necessity criteria/guideline, policy, procedure, and clinical judgment, in order to render coverage determination/recommendation/discharge planning along the continuum of care.
• Utilization of clinical experience and skills in a collaborative process to evaluate and facilitate appropriate healthcare services/benefits for members.
• Identification of members who may benefit from care management programs and facilitation of the referral.
• Identification of opportunities to promote quality effectiveness of healthcare services and benefit utilization.
• Sedentary work involving periods of sitting, talking, and listening.
• Performing other duties as assigned.

Qualifications

• 5+ years of clinical experience as RN (Registered Nurse).
• Ability to work 8-hour shifts, 5-days per week, with rotating days (including some weekends & holidays), supporting Arizona Time Zone.
• Must have an active and unrestricted RN licensure in the state of Arizona or Compact RN licensure.

Requirements

• Previous experience in utilization management.
• Previous experience in both medical and behavioral health fields.
• Previous experience in acute care.
• Strong critical thinking and written communication skills.
• Ability to operate independently.

Education

• Associate’s degree in Nursing.

Benefits

This full‑time position is eligible for a comprehensive benefits package designed to support the physical, emotional, and financial well‑being of colleagues and their families. The benefits for this position include:

• Medical, dental, and vision coverage.
• Paid time off.
• Retirement savings options.
• Wellness programs.
• Other resources, based on eligibility.