The posting
The Sr. Director, Prior Authorization Clinical oversees prior authorization nurse case managers, support staff, claims review nurses, and UM compliance staff to ensure quality, cost-effective, patient-centered care in compliance with UM policies, regulatory requirements, and established standards. Responsibilities include staff supervision, program development, policy implementation, workflow improvement, quality assurance, performance evaluation, compliance monitoring, issue resolution, reporting, and collaboration with medical directors and clinical leadership. The role requires knowledge of CMS and ICE utilization management policies, procedures, and timeliness standards, along with proven management, program oversight, and team leadership experience. Project management experience is preferred.
Essential Duties & Responsibilities include the following :
- Promote medical management principles to ensure the right care is delivered at the right time and in the appropriate setting.
- Collaborate with Medical Directors to develop, implement, and improve UM policies and procedures that support quality, cost-effective care.
- Ensure compliance with health plan, state, and federal regulations, including DMHC, Medicaid, CMS Medicare Part C & D, and NCQA requirements, as applicable.
- Maintain knowledge of CMS and ICE UM policies, denial language, documentation, and timeliness standards.
- Supervise prior authorization nurses, professional claims review nurses, UM coordinators, and compliance staff, including assignments, performance evaluations, and disciplinary actions.
- Serve as a liaison among clinical staff, Medical Directors, providers, and health plans to resolve authorization, utilization management, and care coordination issues.
- Oversee professional claims review nurses and coders in collaboration with Claims to support medical necessity determinations.
- Ensure timely communication, follow-up, and resolution of requests and issues.
- Model compliance and privacy standards, report concerns, and facilitate corrective action.
- Prepare departmental work plans, periodic reports, inter-rater reliability assessments, and audit documentation.
- Coordinate Utilization Management Committee activities and meetings with committee leadership and Medical Directors.
- Perform additional duties as assigned by management.
The pay range for this position at commencement of employment is expected to be between $160,000 year to $180,000 year ; however, base pay offered may vary depending on multiple individualized factors, including market location, job-related knowledge, licensure, skills, and experience.
The total compensation package for this position may also include other elements, including a sign-on bonus and discretionary awards in addition to a full range of medical, financial, and/or other benefits (including 401(k) eligibility and various paid time off benefits, such as vacation, sick time, and parental leave), dependent on the position offered.
Details of participation in these benefit plans will be provided if an employee receives an offer of employment.
If hired, employee will be in an “at-will position” and the Company reserves the right to modify base salary (as well as any other discretionary payment or compensation program) at any time, including for reasons related to individual performance, Company or individual department/team performance, and market factors.
As one of the fastest growing Independent Physician Associations in Southern California, Regal Medical Group, Lakeside Community Healthcare & Affiliated Doctors of Orange County, offers a fast-paced, exciting, welcoming and supportive work environment. Opportunities abound, and enterprising, capable, focused people prosper with us. We promote teamwork, nurture learning, and encourage advancement for all of our employees. We want to see you excel, because we believe that your success is our success.
Full Time Position Benefits:
The success of any company depends on its employees. For us, employee satisfaction is crucial not only to the well-being of our organization, but also to the health and wellness of our members. As such, we are firmly dedicated to providing our employees the options and resources necessary for building security and maintaining a healthy balance between work and life.
Our dedication to our staff is evident in our comprehensive benefits package. We offer a very generous mixture of benefits, including many employer-paid options.
Health and Wellness:
- Employer-paid comprehensive medical, pharmacy, and dental for employees
- Vision insurance
- Zero co-payments for employed physician office visits
- Flexible Spending Account (FSA)
- Employer-Paid Life Insurance
- Employee Assistance Program (EAP)
- Behavioral Health Services
Savings and Retirement:
- 401(k) Retirement Savings Plan
- Income Protection Insurance
Other Benefits:
- Vacation Time
- Company celebrations
- Employee Referral Bonus
- Tuition Reimbursement
- License Renewal CEU Cost Reimbursement Program
- Business-casual working environment
- Sick days
- Paid holidays
- Mileage
Employer will consider for employment qualified applicants with criminal histories in a manner consistent with the requirements of the LA City Fair Chance Initiative for Hiring Ordinance.
Required Qualifications and Skills
- Education and Licensure: Graduate of an accredited Registered Nursing program with a current, active RN license.
- Experience: 5+ years of progressive experience in prior authorization or related healthcare operations within a medical group, IPA, or management company, including claims experience and staff supervision and performance management.
- Leadership and Project Management: Proven ability to develop high-performing teams, lead project development and implementation, monitor productivity, and manage competing priorities and deadlines.
- Regulatory Knowledge: Demonstrated knowledge of CMS, DMHC, DHS, and major California health plan requirements.
- Analytical and Problem-Solving Skills: Strong analytical, organizational, and problem-solving abilities, including experience resolving complex issues in a highly matrixed organization.
- Communication and Relationship Management: Excellent written and verbal communication skills, with the ability to collaborate effectively with all levels of management, health plan auditors, and department leaders.
- Technical Proficiency: Proficiency in Microsoft Office, including Word, Excel, Outlook, and PowerPoint, and the ability to work effectively in a highly computerized environment.
- Professional Attributes: Self-motivated, independent, adaptable, and able to manage confidential matters, work under pressure, reprioritize tasks, and seek guidance when needed.
- Work Location: Ability to work full-time on-site at the West Hills, California, office.
- Requires current CA driver's license and car insurance.
