Prior Authorization Clinical Reviewer

Mercy Care is a not‑for‑profit Medicaid managed‑care health plan serving Arizonans since 1985. This position is within Mercy Care, administered by Aetna, a CVS Health company. Position Summary This role involves reviewing prior authorizations for physical and behavioral health services, documenting and communicating utilization decisions, and coordinating care for members with disabilities and special healthcare needs. The incumbent will manage benefit eligibility, conduct provider and member calls, facilitate care management referrals, and promote quality and efficiency of healthcare services. Responsibilities Review prior authorizations for physical and behavioral health services. Coordinate, document, and communicate all aspects of the utilization/benefit management program. Apply critical thinking and evidence‑based criteria to assess medical necessity for members with disabilities and special healthcare needs. Respond to provider calls related to prior authorization questions and inform members of coverage determinations. Gather clinical information and apply appropriate medical necessity criteria and policy guidelines to produce coverage determinations, recommendations, and discharge planning. Collaborate to evaluate and facilitate appropriate healthcare services/benefits for members. Identify members who may benefit from care management programs and facilitate referrals. Identify opportunities to promote quality and effectiveness of healthcare services and benefit utilization. Perform sedentary duties involving sitting, talking, and listening. Perform other duties as assigned. Qualifications Required Qualifications 5+ years of clinical experience as an RN (Registered Nurse). Ability to work 8‑hour shifts, 5 days per week, with rotating days (including some weekends and holidays) in the Arizona Time Zone. Valid active and unrestricted RN licensure in Arizona or a Compact RN licensure. Associate’s degree in Nursing. Preferred Qualifications Experience in utilization management. Experience in both medical and behavioral health fields. Experience in acute care settings. Strong critical thinking and written communication skills. Ability to operate independently. Pay Range Typical hourly rate: $26.01 – $74.78. The base salary may vary based on experience, education, geography, and other factors. The position is eligible for bonus, commission, or short‑term incentive premiums in addition to base pay. Benefits This full‑time position is eligible for a comprehensive benefits package that includes medical, dental, and vision coverage; paid time off; retirement savings options; wellness programs; and additional resources. Eligibility and details are provided during the application process. Application Deadline Applications will close on 06/02/2026. Equal Opportunity Employer Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state, and local laws. #J-18808-Ljbffr 4004 Aetna Medicaid Administrators