Become a part of our caring community and help us put health first
 

The Manager of National Medicaid Clinical Operations is responsible for managing the day-to-day operations of nonclinical staff involved in the prior authorization process. This role ensures that all prior authorization activities are conducted efficiently and in compliance with federal and state regulations and accreditation bodies. The Manager will report directly to the Associate Director and play a key role in promoting quality improvements, fostering a collaborative work environment, and ensuring that service standards are met.

Key Responsibilities:  

Staff Management: 

• Oversee the hiring, training, and development of clinical and nonclinical staff. 

• Conduct regular performance evaluations and provide coaching and mentoring to staff. 

• Ensure staff are knowledgeable about Medicaid policies and procedures. 

Operational Oversight: 

• Manage the day-to-day operations of clinical and nonclinical services. 

• Develop and implement policies and procedures to ensure efficient and effective operations. 

Compliance and Quality Assurance: 

• Ensure compliance with all regulatory and accreditation requirements. 

• Implement quality assurance measures to maintain high standards of service. 

• Conduct regular audits and reviews to ensure accuracy and consistency in prior authorization review processes. 

Coordination and Collaboration: 

• Promote intradepartmental and cross-market coordination to ensure cohesive operations. 

• Foster collaboration between clinical and nonclinical teams to streamline processes and improve outcomes. 

• Liaise with healthcare providers, payers, and other stakeholders to address operational issues. 

Data and Trend Analysis: 

• Conduct data analysis to identify trends and inform decision-making. 

• Use data-driven insights to optimize workflows and improve service delivery.  

Quality Improvements: 

• Develop and implement quality improvement initiatives to enhance the efficiency and effectiveness of prior authorization. 

• Monitor performance metrics and implement strategies to achieve continuous quality improvement. 

Strategic Planning: 

• Assist in establishing long-range goals, objectives, and plans that align with State-specific and Enterprise Medicaid strategic priorities. 

• Adapt plans to meet the evolving needs of members, providers, and regulatory partners. 

Use your skills to make an impact
 

Required Qualifications

• Active Registered Nurse, RN, license in a state that participates in the enhance licensure, (eNLC) without disciplinary action.

• Minimum 2 years of experience in prior authorization, utilization management or related fields.

• Minimum 2 years of experience as a Team Lead, Subject Matter Expert, (SME), Project Leadership, Charge Nurse

• Experience with Medicaid policies and procedures.

• Knowledge of payer policies, insurance companies and government health programs.

• Ability to work collaboratively with diverse teams and stakeh