Prior Authorization Lead

The Pennant Group

2d•Remote

About The Position

Join Synergy’s dynamic Revenue Cycle team as the Prior Authorization Lead. We are seeking a Tennessee‑based subject matter expert with deep knowledge of Tennessee home health payors to ensure the quality, accuracy, and compliance of authorization decisions. This role provides experienced oversight of authorization workflows, supports frontline teams through quality review and guidance, and helps protect agencies from preventable denials and revenue risk—while also stepping in to design, refine, and execute workflows as needed. About the Role The Prior Authorization Lead is responsible for quality oversight and workflow leadership of prior authorization activities for Tennessee Home Health payors. This role serves as the expert reviewer, escalation resource, and workflow owner, validating authorization work performed by teams, identifying risk, and ensuring payer‑specific requirements are consistently and accurately applied. The position requires extensive Tennessee payer expertise, prior leadership experience, and the ability to both guide teams and personally step into workflow execution when needed.

Requirements

Must reside in the state of Tennessee.
Minimum of 5+ years of experience in home health prior authorization with Tennessee payors.
Expert‑level knowledge of Tennessee Medicaid (TennCare), Medicare Advantage, and commercial authorization requirements.
Prior experience leading, mentoring, or overseeing teams performing authorization work.
Strong understanding of how authorization requirements align with home health plans of care.
Ability to design, implement, and step into authorization workflows as needed.
Excellent analytical, communication, and clinical interpretation skills.

Responsibilities

Perform quality reviews of prior authorization submissions and determinations for Tennessee home health payors.
Validate that authorizations align with payer requirements, clinical documentation, and plans of care.
Identify errors, gaps, or risk conditions that could lead to denials or delayed reimbursement.
Serve as the final quality checkpoint for complex, high‑risk, or escalated authorization cases.
Own prior authorization workflows for Tennessee home health payors, ensuring processes are clear, effective, and consistently applied.
Design, refine, and document workflows to support timely and accurate authorization decisions.
Step directly into authorization workflow execution as needed to support coverage, backlog reduction, or complex cases.
Translate payer requirements into practical, actionable workflows for frontline teams.
Serve as the organization’s subject matter expert on Tennessee home health payors and authorization rules.
Maintain advanced knowledge of Tennessee Medicaid (TennCare), Medicare Advantage, and commercial payors, including but not limited to TennCare MCOs, UnitedHealthcare, Humana, and Blue Cross Blue Shield.
Interpret payer guidance and ensure consistent application across teams and agencies.
Proactively monitor payer policy changes and assess operational and financial impact.
Provide real‑time guidance and feedback to authorization teams to improve accuracy and consistency.
Partner with authorization leaders to calibrate standards and resolve recurring quality issues.
Support onboarding and training by reinforcing Tennessee‑specific authorization expectations.
Share best practices and workflow updates to strengthen team performance and first‑pass accuracy.
Collaborate closely with intake, clinical leadership, and case management teams to ensure authorization requirements are met prior to service delivery.
Ensure authorization approvals, limitations, and visit parameters are clearly communicated to clinical teams.
Partner with billing and collections teams to mitigate authorization‑related denials and appeals.
Track quality trends, workflow gaps, and authorization‑related denial drivers.
Identify systemic risks and recommend workflow or process improvements.
Support audits, payer reviews, and internal compliance initiatives as needed.
Provide concise reporting on quality outcomes, risks, and payer‑specific trends.