-Candidate must reside in Ohio.

As part of the bold vision to deliver the "Next Generation" of managed care in Ohio Medicaid, Ohio RISE will help struggling children and their families by focusing on the individual with strong coordination and partnership among MCOs, vendors, and ODM to support specialization in addressing critical needs.

The OhioRISE Program is designed to provide comprehensive and highly coordinated behavioral health services for children with serious/complex behavioral health needs involved in, or at risk for involvement in, multiple child-serving systems.

The Prior Authorization Representative supports comprehensive coordination of medical services including intake, screening and referrals to Aetna Medical Services Programs. Promotes/supports quality effectiveness of Healthcare Services.

Additional responsibilities to include but not limited to the following:

- Performs intake of calls from members or providers regarding services via telephone, fax, EDI.
- Utilizes eTUMS and other Aetna system to build, research and enter member information.
- Screens requests for appropriate referral to medical services staff.
- Approve services that do not require a medical review in accordance with the benefit plan.
- Performs intake of calls from members or providers regarding services via telephone, fax, EDI.
- Utilizes eTUMS and other Aetna system to build, research and enter member information.
- Screens requests for appropriate referral to medical services staff.
- Approve services that do not require a medical review in accordance with the benefit plan.
- Performs non-medical research including eligibility verification, COB, and benefits verification.
- Maintains accurate and complete documentation of required information that meets risk management, regulatory, and accreditation requirements.
- Promotes communication, both internally and externally to enhance effectiveness of medical management services (e.g., claim administrators, Plan Sponsors, and third-party payers as well as member, family, and health care team members respectively). Protects the confidentiality of member information and adheres to company policies regarding confidentiality.
- Communicate with Aetna Case Managers, when processing transactions for members active in this Program.
- Supports the administration of the precertification process in compliance with various laws and regulations, URAQ and/or NCQA standards, where applicable, while adhering to company policy and procedures.
- Places outbound calls to providers under the direction of Medical Management Nurses to obtain clinical information for approval of medical authorizations. Uses Aetna Systems such as QNXT, ProFAX, ProPAT, and Milliman Criteria.
- Communicates with Aetna Nurses and Medical Directors, when processing transactions for members active in this Program.

- Submits pending member eligibility for OhioRISE new inpatient hospitalization admissions and completes CANS inpatient.

- Sedentary work involving significant periods of sitting, talking, hearing and keying. Work requires visual acuity to perform close inspection of written and computer-generated documents as well as a PC monitor. Working environment includes typical office conditions.

Required Qualifications

- 2 years' experience as a medical assistant, office assistant or other clinical experience.
- Familiarity with basic medical terminology and concepts used in care management.
- Computer literacy in order to navigate through internal/external computer systems, including Excel and Microsoft Word.

- Ability to work on a rotation schedule for weekends/holidays.

Education

High School Diploma or equivalent G.E.D.

Pay Range

The typical pay range for this role is:

$17.00 - $25.65

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.

In addition to your compensation, enjoy the rewards of an organization that puts our heart into caring for our colleagues and our communities. The Company offers a full range of medical, dental, and vision benefits. Eligible employees may enroll in the Company's 401(k) retirement savings plan, and an Employee Stock Purchase Plan is also available for eligible employees. The Company provides a fully-paid term life insurance plan to eligible employees, and short-term and long term disability benefits. CVS Health also offers numerous well-being programs, education assistance, free development courses, a CVS store discount, and discount programs with participating partners. As for time off, Company employees enjoy Paid Time Off ("PTO") or vacation pay, as well as paid holidays throughout the calendar year. Number of paid holidays, sick time and other time off are provided consistent with relevant state law and Company policies.

For more detailed information on available benefits, please visit Benefits | CVS Health

We anticipate the application window for this opening will close on: 12/06/2024

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