Duration: 6 Months
Start:02/24/2025
Job Description:
Analyzes all prior authorization requests to determine medical necessity of service and appropriate level of care in accordance with national standards, contractual requirements, and a member's benefit coverage. Provides recommendations to the appropriate medical team to promote quality and cost effectiveness of medical care.
Responsibilities:
Performs medical necessity and clinical reviews of authorization requests to determine medical appropriateness of care in accordance with regulatory guidelines and criteria
Works with healthcare providers and authorization team to ensure timely review of services and/or requests to ensure members receive authorized care
Coordinates as appropriate with healthcare providers and interdepartmental teams, to assess medical necessity of care of member
Escalates prior authorization requests to Medical Directors as appropriate to determine appropriateness of care
Assists with service authorization requests for a member’s transfer or discharge plans to ensure a timely discharge between levels of care and facilities
Collects, documents, and maintains all member’s clinical information in health management systems to ensure compliance with regulatory guidelines
Assists with providing education to providers and/or interdepartmental teams on utilization processes to promote high quality and cost-effective medical care to members
Provides feedback on opportunities to improve the authorization review process for members
Performs other duties as assigned
Complies with all policies and standards
Education/Experience:
Requires Graduate from an Accredited School of Nursing or Bachelor’s degree in Nursing and 2 - 4 years of related experience.
Clinical knowledge and ability to analyze authorization requests and determine medical necessity of service preferred.
Knowledge of Medicare and Medicaid regulations preferred.
Knowledge of utilization management processes preferred.
License/Certification:
LPN - Licensed Practical Nurse - State Licensure required
About Accede:
Accede Solutions is a Nationally Certified Search firm providing services in multiple sectors. We are a Women and Minority-owned Business with a strong emphasis on Diversity, Equity, and Inclusion (DEI). We have managed and Implemented Talent Acquisition and Talent Management processes and had successful engagement with clients in the areas of Financial Services, Technology, healthcare and professional services. We provide a full range of talent acquisition and management services designed to maximize the efficiency of your information management operation.
From executive recruiting, to contract-to-hire placement, to contract employment, we offer solutions for your day-to-day workflow issues as well as workload spikes and special projects. We also specialize in retained executive search focused on recruiting distinctive leaders and C level roles. With a track record of successfully recruiting key human capital leaders, we have earned a reputation for insightful and nuanced cultural advisory work built on a platform of strong capability supported by a rigorous and artful approach in assessing cultural fit.
We were listed as Fast 100 Asian American firm in 2023 & 2024 by USPAACC and listed as # 2115 fastest growing companies in US in INC5000
Equal Opportunity Employer: Females/Minorities/Veterans/Individuals with Disabilities
Accede is committed to equal employment opportunity to all employees and applicants without regard to race, religion, color, gender identity, ethnicity, age, national origin, sexual orientation, disability status, veteran status or any other category protected by applicable law.
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