Medical Necessity Specialist

2 weeks ago


Sunrise Manor, Nevada, United States Community Care Plan Full time
Role Overview

We are seeking a detail-oriented Medical Necessity Specialist to join our team at Community Care Plan. As a key member of our Medical Management department, you will be responsible for reviewing prior authorization requests and ensuring compliance with regulatory guidelines.

Key Responsibilities
  • Prior Authorization Reviews: Conduct thorough reviews of prior authorization requests to determine medical necessity and appropriateness, utilizing standardized Review Criteria.
  • Caseload Management: Prioritize and manage assigned caseload, ensuring timely completion and resolution of requests.
  • Collaboration and Communication: Work closely with Medical Directors, physicians, and other stakeholders to coordinate requests and resolve issues.
Requirements and Qualifications
  • Clinical Experience: A minimum of two years of utilization review/case management experience, preferably in an acute care setting.
  • Licensure: Current unrestricted Florida RN or LPN License.
  • Knowledge and Skills: Familiarity with InterQual and Milliman Criteria, Florida Medicaid Program, and CMS Guidelines.
About Our Organization

Community Care Plan is a leading provider of healthcare services, dedicated to delivering high-quality care to our patients. We are committed to fostering a diverse and inclusive work environment that values employee growth and development.

Compensation and Benefits

The estimated salary for this position is $60,000 - $80,000 per year, depending on experience. We offer a comprehensive benefits package, including health insurance, retirement savings plan, and paid time off.



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