Monitors, negotiates, and provide care management for service authorizations and approvals for consumers of EastRidge Health Systems. Maintain a thorough knowledge of Medicaid/Medicare, third party payers and/or other licensing regulations. Monitor service authorizations to managed care entities. Negotiate service authorizations with managed care entities. Review all authorization denial and closure to determine need for appeal and renegotiation. Analyze trends for service approvals and denials. Develop service strategies with direct care staff to address service denials. Provide clinical analysis of treatment plans and evaluations as become necessary to the prior authorization process. Analyze and make recommendations as it pertains to practice standards and service utilization. Assist in developing and implementing training strategies for staff on issues related to care management and service plan development.
A Bachelor's degree plus five years of clinically related experience is required. A Master's degree with job related experience is preferred.