Prior Authorization Clinical Reviewer

CVS Health

Clinical Reviewer managing prior authorization requests within Mercy Care, a Medicaid managed-care health plan. Engaging in utilization management and collaborating on healthcare services for members with disabilities and special needs.

Posted 4/24/2026full-timeRemote • Arizona • 🇺🇸 United StatesMid-LevelSenior💰 $26 - $75 per hourWebsite

About the role

Key responsibilities & impact

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.

Requirements

What you’ll need

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

Benefits

Comp & perks

medical, dental, and vision coverage
paid time off
retirement savings options
wellness programs
other resources, based on eligibility

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills & Tools

clinical experienceutilization managementmedical necessity criteriaevidence-based caredischarge planningcare managementdocumentationcoordination of servicescritical thinkingbehavioral health

Soft Skills

communication skillsindependencecollaborationorganizational skillsproblem-solving

Certifications

RN licensureCompact RN licensure