We are seeking a qualified vendor to provide professional services supporting Medicaid operations in two key areas: prior authorization (PA) reviews and utilization/quality reviews for inpatient medical and psychiatric hospitalizations.

The ideal partner will help process approximately 200 PA cases, 200 medical utilization reviews, and 10 psychiatric reviews per month. Responsibilities include evaluating requests based on medical necessity, conducting retrospective peer reviews, supporting appeals and reconsiderations, and submitting timely compliance reports.

Key requirements include:

• Licensed Registered Nurses (in SD or a compact state)

• QIO-like entity certification with CMS

• Ability to meet turnaround times (7 days for PA, 60 days for retrospective reviews)

• Strong documentation, reporting, and communication processes