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.

This is a full-time teleworker position in Ohio.
Candidate must reside in Ohio.

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.

• 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.

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.

Pay Range
The typical pay range for this role is:
Minimum: 17.00
Maximum: 27.16

Please keep in mind that this range represents the pay range for all positions in the job grade within which this position falls. The actual salary offer will take into account a wide range of factors, including location.

Required Qualifications

• 2-4 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.

Preferred Qualifications

• Effective communication, telephonic and organization skills.
• Strong customer service skills to coordinate service delivery including attention to customers, sensitivity to issues, proactive identification and resolution of issues to promote positive outcomes for members.
• Ability to effectively participate in a multi-disciplinary team including internal and external participants.
• Previous call center experience.

Education

• High School Diploma or G.E.D.

Business Overview
Bring your heart to CVS Health
Every one of us at CVS Health shares a single, clear purpose: Bringing our heart to every moment of your health. This purpose guides our commitment to deliver enhanced human-centric health care for a rapidly changing world. Anchored in our brand — with heart at its center — our purpose sends a personal message that how we deliver our services is just as important as what we deliver.

Our Heart At Work Behaviors™ support this purpose. We want everyone who works at CVS Health to feel empowered by the role they play in transforming our culture and accelerating our ability to innovate and deliver solutions to make health care more personal, convenient and affordable.
We strive to promote and sustain a culture of diversity, inclusion and belonging every day.
CVS Health is an affirmative action employer, and is an equal opportunity employer, as are the physician-owned businesses for which CVS Health provides management services. We do not discriminate in recruiting, hiring, promotion, or any other personnel action based on race, ethnicity, color, national origin, sex/gender, sexual orientation, gender identity or expression, religion, age, disability, protected veteran status, or any other characteristic protected by applicable federal, state, or local law.