Job Description:
• Take inbound calls from providers, pharmacies, members, and other callers
• Provide professional and courteous phone assistance through the criteria-based prior authorization process
• Maintain complete, timely, and accurate documentation of reviews
• Transfer clinical questions, escalations, and judgment calls to the pharmacist team
• Make outbound calls as needed
• Review and process prior authorizations received via fax and ePA
• Monitor and respond to inquiries via department mailboxes
• Enter prior authorization requests and verify required documentation
• Verify insurance coverage to determine whether prior authorization is required
• Inspect medical records and clinical documentation for medical necessity and appropriateness
• Assist with appeals for denied or rejected requests
• Document patient details, medical codes, and authorization status in electronic systems
• Identify process inefficiencies and propose operational improvements
• Communicate with healthcare providers to obtain information, clarify documentation, and communicate decisions or requirements
• Maintain awareness of regulations, medical coding guidelines, and prior authorization changes through training and knowledge sharing
• Ensure adherence to regulatory guidelines, company policies, and industry standards
Requirements:
• 6 months of Customer Service/Pharmacy Technician Experience
• High School Diploma or equivalent GED
• Regular and predictable attendance
• Willingness to work mandatory overtime/extended work week when needed
• Willingness to travel when needed
• Ability to manage work volume by handling inbound calls/fax requests using courteous and professional behavior
• Compliance with departmental, company, state, and federal requirements when processing information
• Ability to maintain accuracy of information provided to internal and external customers
• Ability to work long periods sitting, talking on the phone, and reading a computer screen
• Home workspace must comply with CVS Health privacy and security policies
• Confidential computer information and telephone conversations must not be accessible or audible to others in the home
Benefits:
• CVS Health bonus, commission or short-term incentive program in addition to base pay
• Medical, dental, and vision coverage
• Paid time off
• Retirement savings options
• Wellness programs
• Other resources supporting physical, emotional, and financial well-being
• Remote work from a home office
• Comprehensive benefits package for eligible full-time colleagues