Manager, Preservice Review

Avalon Administrative Services LLC

1d • Remote

About The Position

The Manager, Preservice Review manages the day-to-day operations of the preservice review process for prior authorizations while collaboratively partnering and clinically supporting Avalon’s medical director leadership within the clinical review space, to drive consistent, efficient, and compliant execution of prior authorizations in accordance with established client, regulatory, and industry standard service level agreements.

This position is eligible for remote work, but quarterly travel will be required to Avalon's corporate office located in Tampa, Florida.

Requirements

• Associate’s degree
• Active Unrestricted Multi-State Nursing (RN Only) License
• 5+ years’ experience in performing preservice review, +1-2 years direct or indirect people leadership
• Ability to read and interpret documents.
• Excellent communication skills, including good grammar, verbal and diction.
• Ability to navigate and master proprietary software programs and proficient in MS Office with basic computer and keyboarding skills.
• Knowledge of managed care processes, including prior authorization and medical necessity criteria.
• Excellent leadership and interpersonal skills to manage direct and cross-functional teams and stakeholders.

Nice To Haves

• Bachelor’s degree preferred.
• Proficiency in healthcare IT systems, data analysis, and process optimization.
• Able to recognize and translate insights into actionable strategies (i.e., trends into process improvements).
• Previous experience in a small, private equity backed company helpful.

Responsibilities

• Manage the preservice review process from intake to final determination, ensuring timely and accurate processing of prior authorizations in compliance with regulatory/SLA requirements.
• Train new Nurse Reviewers and Intake Coordinators. Ensures training materials and related SOPs are current and accurate for business owned processes.
• Manage scheduling of Intake Coordinators and Nursing staff.
• Monitor and evaluate individual Intake and Nurse clinical team performance, balancing quality with productivity, to ensure adherence to quality, NCQA, SLA standards.
• Responsible for analyzing performance (individual and by team) trends, inefficiencies, and opportunities making data driven recommendations for improvements/change.
• Partner and collaborate with senior clinical leaders (MDs) in application of clinical criteria and medical necessity to determine medical necessity throughout the clinical review process.
• Acts as primary contact for escalated calls and/or escalated issues or calls that require additional research and/or special handling.
• Serve as subject matter expert on prior auth policies, procedures, and systems during internal and external audits.
• Perform other duties as assigned such as managing PSR UAT for system upgrades, enhancements.

What This Job Offers

• Job Type: Full-time
• Career Level: Manager
• Education Level: Associate degree
• Number of Employees: 101-250 employees