Prospective Review (Prior Authorization) Clinical Supervisor
The Prior Authorization (Prospective Review) Nurse Supervisor, under the direction of the Utilization Management (UM) Manager / Director and/or Medical Director, ensures prospective review / prior authorization requests are completed in a timely fashion to meet contractual requirements and ensures 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; and assists the Utilization Review Manager, Prior Authorization and department Directors in preparation for audits and other regulatory activities.
Ensures prior authorization requests are completed accurately, thoroughly, and in a timely fashion to meet contractual requirements and ensures all reviews are conducted using nationally recognized and evidence-based standards, with duties including but not limited to: Coordinates and follows the established preauthorization review process for outpatient and inpatient services; produces volume of work to meet position requirements; evaluates clinical documentation when determining benefit coverage including appropriateness and level of care; reviews prior authorization requests with Medical Directors as directed; verifies Notice of Action documents meet requirements; assists Member Services, Claims, and Provider Services department staff with issues that require clinical interpretation or explanation; communicates with providers or agencies as needed; documents processes accurately, thoroughly, and timely in the care management system.
Manage day to day activity of assigned team; ensures staff is trained; completes IRR audits per policy; coaches and mentors staff; works with Manager on employee performance issues; assists with employee evaluations; monitors phone activity and staff productivity. Ensures team meets budget and performance goals.
Participates in Quality Improvement projects as directed. Performs audits of case files and staff work as directed. Assists the manager, director, and others in preparation for audits and other regulatory activities.
Bachelor's degree required
Arizona licensed (in good standing) Registered Nurse (RN) required
One (1) or more years of managed care experience preferred
Prospective review experience preferred; knowledge of utilization management principles
Two (2) or more years of managing others
Skills in navigating software programs
Position must be located in Arizona