Director, Prior Authorization Non-Clinical

Position Summary:

The role of the Director, Prior Authorization is to oversee the prior authorization non-clinical staff members, primarily coordinators in order to promote quality, cost effectiveness intake and review of pre-certification referrals to ensure strict adherence to all UM policies and procedures within the affiliated medical groups for which this position has oversight. The Director coordinates, plans and manages staff activities; develops and maintains efficient work processes to meet compliance and customer service KPIs; adheres to and supports Medical Director program goals and objectives; makes staff assignments; develops or assists in the development of related prior authorization policies, incorporating current literature and professionally recognized standards; develops or assists in development and implementation of policy and plans for effective patient centered utilization management; together with the medical director, interprets and administers pertinent laws; through direct and indirect contact, evaluates staff and determines the quality of their work efforts; develops and/or implements effective ongoing programs to measure, assess and improve quality of processes and workflows, services delivered to patients; develops productive work teams; recommends disciplinary actions; collaborates with clinical leadership for educational programs; represents the department in meetings of professional and/or community organizations; compiles data and prepares periodic reports; responsible for coordinating and providing appropriate coverage; maintains contacts with individuals both within and outside of the department who might impact on program activities; assures optimal quality of care and service is provided; participates in Quality Assurance Programs as needed; intervenes in crisis situations and investigates all unusual incidents; leads and participates in meetings; may speak on behalf of department. This position requires general knowledge of regulatory requirements such as those outlined by CMS, DMHC, and HICE UM processes/policies/procedures and timeliness standards.  This role has management level experience including but not limited to: staff oversight, program management, and issue resolution. Project Management experience is a plus.

Essential Duties and Responsibilities include the following:

1. Understand, promote and manage with the principles of medical management to facilitate the right care at the right time in the right setting.
2. In collaboration with the Medical Director, identifies the need for and participates in the development and implementation of Utilization Management policies and procedures and to promote cost-effectiveness and improved quality.
3. Oversee compliance with all health plan, state and federal regulatory requirements (e.g., DMHC, Medicaid, CMS Medicare Part C & D, NCQA where applicable) with respect to prior authorization services, such as turnaround times and appropriate documentation.
4. Understand CMS and ICE UM processes/policies/procedures, especially with respect to ICE and CMS denial language and timeliness criteria, with respect to prior authorization services.
5. Provide direct supervisory oversight to prior authorization review nurses, professional claims review nurses, UM coordinators and UM compliance staff, including, but not limited to daily work assignments, special project assignments, assistance with performance reviews and disciplinary actions as needed/required.
6. Communicate effectively and functions as liaison between nurse and physician reviewers, medical directors, coordinators, PCP and specialist providers, and health plans daily or as indicated regarding any UM or referral authorization issues, as well as care coordination issues.
7. Oversight of the professional claims review nurse team (nurses/coders), who work with the claims department to assist in making medical necessity determinations of submitted claims.
8. Demonstrates the ability to follow through with requests, sharing of critical information, returning phone calls and getting back to individuals in a timely manner.
9. Sets an example for staff by maintaining exemplary compliance and privacy, and reporting compliance and privacy issues and facilitating resolution of others’ issues.
10. Assists as necessary in gathering/preparing necessary reports, such as department work-plans, quarterly/semi-annual/annual reports, inter-rater reliability surveys, and plan audits.
11. Works with the Utilization Management Committee Chair, and when necessary Medical Management Vice Presidents, Chief Medical Officers or Medical Directors to coordinate acti