Manager, Prior Authorization UM – Aetna Medicaid Texas – RN

R0739137 At CVS Health, we’re building a world of health around every consumer and surrounding ourselves with dedicated colleagues who are passionate about transforming health care. As the nation’s leading health solutions company, we reach millions of Americans through our local presence, digital channels and more than 300,000 purpose-driven colleagues – caring for people where, when and how they choose in a way that is uniquely more connected, more convenient and more compassionate. And we do it all with heart, each and every day. Position Summary The Manager of Prior Authorization oversees the daily operations of the prior authorization team, ensuring timely and accurate processing of authorization requests in compliance with regulatory and payer requirements. This role is responsible for staff supervision, workflow optimization, performance monitoring, and collaboration with clinical and administrative teams to support patient access and care coordination. This is a fully remote position. Eligible candidates may live anywhere in the contiguous United States. Key Responsibilities: • Lead and manage the prior authorization team, including hiring, training, scheduling, and performance evaluations. • Ensure timely review and processing of prior authorization requests for medical services, procedures, and medications. • Monitor productivity and quality metrics; implement process improvements to enhance efficiency and accuracy. • Serve as a liaison between providers, payers, and internal departments to resolve authorization issues. • Stay current with payer policies, regulatory changes, and industry best practices. • Develop and maintain standard operating procedures (SOPs) for prior authorization workflows. • Collaborate with clinical leadership to ensure alignment with care delivery goals. • Manage escalations related to denied authorizations. • Prepare reports and dashboards for leadership on authorization trends, turnaround times, and team performance. Required Qualifications • Registered Nurse (RN) with an active and unrestricted licene in state of residence • 5+ years of experience in prior authorization, utilization management, or related healthcare operations. • 3-5 years leadership experience • Strong knowledge of payer requirements, medical terminology, and healthcare coding (ICD-10, CPT). • Excellent communication, leadership, and problem-solving skills. • Proficiency in EMR systems and authorization platforms. • Knowledge of the regulations, standards, and policies which relate to medical management • Demonstrated ability to manage workload and meet deadlines • Ability to cover weekends at supervisory capacity Preferred Qualifications • 3-5 years Managed Care expeirence • Experience with Medicare, Medicaid, and commercial insurance plans. • Familiarity with NCQA accreditation standards. Education Registered Nurse, BSN preferred Anticipated Weekly Hours 40 Time Type Full time Pay Range The typical pay range for this role is: $87,035.00 - $187,460.00 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. Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong. Great benefits for great people We take pride in our comprehensive and competitive mix of pay and benefits – investing in the physical, emotional and financial wellness of our colleagues and their families to help them be the healthiest they can be. In addition to our competitive wages, our great benefits include: • Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan. • No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching. • Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility. For more information, visit https://jobs.cvshealth.com/us/en/benefits We anticipate the application window for this opening will close on: 11/01/2025 Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws. Apply tot his job Apply To this Job