Manager I Medical Management (Prior Authorizations) - Florida Medicare

Anticipated End Date:

2025-08-16

Position Title:

Manager I Medical Management (Prior Authorizations) - Florida Medicare

Job Description:

Manager I Medical Management (Prior Authorizations) - Florida Medicare

 

Office Locations: This role is based in Florida at either our Tampa or Miami PulsePoint Offices.

• 5411 Sky Center Drive, Tampa, FL 33607

• 11430 NW 20th Street, STE 300, Miami, FL 33172

 

Florida residency is a requirement for this position.

 

In Office Expectation: Hybrid 2; This role requires associates to be in-office 3 days per week, fostering collaboration and connectivity, while providing flexibility to support productivity and work-life balance. This approach combines structured office engagement with the autonomy of virtual work, promoting a dynamic and adaptable workplace.

 

Please note that per our policy on hybrid/virtual work, candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless an accommodation is granted as required by law.

 

The Manager I Medical Management (Prior Authorizations) is responsible for managing a team of clinicians charged with promoting quality member outcomes, optimizing member benefits, and promoting effective use of resources.

 

How You Will Make an Impact

Primary duties may include, but are not limited to:

• Ensures adherence to medical policy and member benefits in providing service that is medically appropriate, high quality, and cost effective.

• Areas managed may include authorizing inpatient admissions, outpatient services, focused surgical and diagnostic procedures, out of network services, and appropriateness of treatment setting by utilizing the applicable medical policy and industry standards, accurately interpreting benefits and managed care products, and steering members to appropriate providers, programs or community resources.

• Applies clinical knowledge to work with facilities and providers for care-coordination.

• May also manage appeals for services denied.

• Hires, trains, coaches, counsels, and evaluates the performance of direct reports.

 

Minimum Requirements:

• Requires a HS diploma or equivalent and a minimum of 5 years’ acute care clinical experience; or any combination of education and experience, which would provide an equivalent background.

Preferred Skills, Capabilities, and Experiences:

• Associates degree or bachelor’s degree in Nursing is strongly preferred.

• A current active unrestricted RN license is strongly preferred.

• 5+ years of utilization management experience strongly desired.

• Exposure to Overpayment Claim Adjustments (OCA) related to Medicare or Accountable Care Organizations (ACOs) participating in the Medicare program strongly preferred.

• Exposure and baseline knowledge of the Centers for Medicare & Medicaid Services (CMS) strongly preferred.

• Leadership skills with the ability to motivate and maintain a cohesive team.

• Strong oral, written, and interpersonal communication skills.

• Ability to problem-solve, critically think, and facilitate long term planning.

• Analytical and growth mindset skills strongly preferred.

• Advanced understanding of prior authorizations is strongly preferred.

• Florida Medicare knowledge preferred.

For URAC accredited areas, the following professional competencies apply: Associates in this role are expected to have strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.

If this job is assigned to any Government Business Division entity, the applicant and incumbent f