Prior Authorization Clinical Manager
The Prior Authorization Clinical Manager, under the direction of the Utilization Management (UM) leaders and/or Medical Director(s), ensures prospective review/prior authorization requests are completed in a timely manner to meet contractual requirements and all reviews are conducted using nationally recognized and evidence-based standards. Participates in Quality Improvement Projects as directed; performs audits of medical records as directed; assists the internal and external departments in preparation for audits and other regulatory activities.
Manages the day-to-day activity of assigned team, ensures staff are trained and their is adequate coverage, completes IRR audits per policy, coaches and mentors staff, works with Director on employee performance issues, completes employee evaluations, monitors phone activity and staff productivity. Ensures team meets budget and performance goals.
Participates in the Quality Improvement Projects as directed. Performs audits of case files and staff work. Reviews and/or drafts policies and procedures that support the operation.
Prepares for audits and other regulatory activities. Completes reports and documentation required by Compliance department.
Health Choice exists to improve the health and well-being of the individuals we serve through our health plans, integrated delivery systems and managed care solutions. We strive to recruit and retain only the finest health care professionals with the highest levels of integrity, compassion and competency. If you are driven by your own personal commitment to these values and desire to work in a team-focused, collaborative and supportive environment - while still being valued for your individual strengths - Health Choice is the place for you.
Equal Opportunity Employer Minorities/Women/Veterans/Disabled
Arizona nursing license (Registered Nurse / RN) required
Skills in navigating software programs / computer skills required
Bachelor's degree in Nursing preferred
Strong clinical experience; critical thinking skills
One (1) or more years of managed care experience preferred
Prospective review experience preferred; knowledge of utilization management principles
Two (2) or more years managing others preferred
Position must be located in Arizona
Ability to communicate clearly with employees at all organizational levels and across differing cultural background