Manager, Prior Authorization Operations Clinical Compliance

Medical Mutual•Cleveland, OH

9d•Hybrid

About The Position

Ensures timely, accurate, and clinically appropriate authorization determinations while maintaining full compliance with federal, state, accreditation, and internal regulatory requirements. Oversees daily PA operations, compliance monitoring, audit readiness, corrective action planning, and workflow alignment across Clinical Quality Health Services. Partners closely with UM, CM, Quality, IT, and external vendors to ensure high quality, efficient, and compliant clinical operations.

Requirements

Graduate of a registered nursing program approved by the Ohio State Nursing Board.
8+ years of experience in Utilization Management, Prior Authorization, Clinical Review, or Clinical Compliance.
3+ years of leadership or supervisory experience.
Strong knowledge of CMS regulations, state UM requirements, NCQA/URAC standards, and medical necessity criteria (InterQual, MCG).
Experience with compliance audits, CAP development, and regulatory monitoring.
Registered Nurse with current State of Ohio license required.
Comprehensive knowledge of prior authorization operations, clinical review workflows, utilization management, and benefit interpretation.
Comprehensive knowledge of InterQual, MCG, Corporate Medical Policies, clinical documentation, and medical necessity criteria.
Strong knowledge of CMS, state UM requirements, NCQA/URAC standards, HIPAA, NQTLs, audits, and corrective action processes.
Strong knowledge of claims processing, medical terminology, payment analysis, cost containment, ICD-10, CPT, and HCPCS coding.
Knowledge of managed care, care coordination, disease progression, levels of care, patient outcomes, and community resources.
Ability to analyze KPIs, identify trends, prepare reports, and support performance improvement initiatives.
Proficiency with Microsoft Office, Excel reporting, prior authorization platforms, and clinical decision-support tools.
Strong communication, collaboration, vendor partnership, change leadership, and staff development skills.

Nice To Haves

Bachelor of Science in Nursing preferred.

Responsibilities

Manages daily prior authorization and clinical compliance operations, including workload distribution, productivity, quality, and service performance.
Provides coaching, mentoring, and competency development for PA reviewers and clinical compliance staff.
Prepares operational and compliance reports for leadership, committees, and regulatory bodies.
Oversees policy and workflow adherence, performance management, hiring, training, and evaluation of assigned staff.
Ensures timely, accurate, and compliant determinations using InterQual, MCG, and CMP criteria and benefit guidelines.
Manages escalations, complex cases, and high impact determinations.
Partners with UM, CM, Quality, IT, Provider Relations, and external vendors to maintain compliant and efficient operations.
Supports implementation of new systems, workflows, and process improvements that strengthen operational effectiveness and regulatory compliance.
Monitors operational and compliance KPIs and report trends to leadership.
Fosters a culture of accountability, transparency, and continuous improvement.
Evaluates individual and team performance to ensure departmental and organizational goals related to utilization, cost, quality, and productivity are met.
Performs other duties as assigned.

Benefits

Laptop, monitors, keyboard, mouse and headset provided.
Access to on-site fitness centers or gym membership reimbursement.
On-site cafeteria.
Discounts at many places.
Opportunity to earn cash rewards for shopping with customers.
Business casual attire, including jeans.
Employee bonus program.
401(k) with company match up to 4% and an additional company contribution.
Health Savings Account with a company matching contribution.
Excellent medical, dental, vision, life and disability insurance.
Access to an Employee Assistance Program.
Company holidays.
Up to 16 PTO days during the first year of employment with options to carry over unused PTO time.
Parental leave for eligible employees who become parents through maternity, paternity or adoption.
Career development programs and classes.
Mentoring and coaching.
Tuition reimbursement up to $5,250 per year.
Diverse, inclusive and welcoming culture with Business Resource Groups.