What are the responsibilities and job description for the Prior Authorization Nurse Reviewer (Medicaid Services) position at E Logic?
The Prior Authorization Nurse Reviewer will support the South Dakota Department of Social Services (DSS) in reviewing and processing prior authorization requests for select Medicaid and CHIP-covered services. The role is essential to ensuring timely and medically necessary care delivery, with a caseload of approximately 200 prior authorization reviews per month. This role will be performance for 1 year.
Responsibilities:
- Review prior authorization (PA) requests for medical and behavioral health services based on medical necessity, DSS policy, and federal guidelines.
- Ensure determinations are made within 7 calendar days of request receipt.
- Provide clear, well-documented justifications for approvals or denials.
- Communicate with providers via secure email or fax and respond to related inquiries.
- Support appeals and facilitate Medical Director reviews for denied services.
- Mail denial and transition notices to recipients, ensuring timely delivery and compliance.
- Participate in quality checks, audits, and continuous process improvement.
Minimum Qualifications:
- Active Registered Nurse (RN) license in South Dakota or a compact state.
- Familiarity with Medicaid/CHIP programs, medical necessity guidelines, and clinical documentation.
- Strong written communication skills and attention to detail.
- Ability to work independently and meet strict turnaround times.
- Experience with durable medical equipment (DME), out-of-state care requests, or surgical procedures.
- Prior work with Medicaid or fee-for-service programs.
- Telehealth or remote review experience.
Important Notice:
This role is part of a proposal for the South Dakota Department of Social Services (DSS) Agency. Hiring is contingent upon the selection of the consultant. Selected candidates will be included in the proposal and must authorize the use of their resume for submission.
