Sr. Director, Prior Authorization Clinical
About The Position
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. The role is responsible for 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 position requires knowledge of CMS and ICE utilization management policies, procedures, denial language, documentation, and timeliness standards, as well as proven management, program oversight, and team leadership experience. The role works full-time on-site at the West Hills, California, office. The expected pay range at commencement of employment is $160,000 to $180,000 per year. The compensation package may also include a sign-on bonus and discretionary awards, along with benefits such as medical, financial, and paid-time-off benefits.
Requirements
- Graduate of an accredited Registered Nursing program with a current, active RN license.
- 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.
- Proven ability to develop high-performing teams, lead project development and implementation, monitor productivity, and manage competing priorities and deadlines.
- Demonstrated knowledge of CMS, DMHC, DHS, and major California health plan requirements.
- Strong analytical, organizational, and problem-solving abilities, including experience resolving complex issues in a highly matrixed organization.
- Excellent written and verbal communication skills, with the ability to collaborate effectively with all levels of management, health plan auditors, and department leaders.
- Proficiency in Microsoft Office, including Word, Excel, Outlook, and PowerPoint, and ability to work effectively in a highly computerized environment.
- Self-motivated, independent, adaptable, and able to manage confidential matters, work under pressure, reprioritize tasks, and seek guidance when needed.
- Ability to work full-time on-site at the West Hills, California, office.
- Current California driver's license and car insurance.
Nice To Haves
- Project management experience is preferred.
Responsibilities
- 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.
Benefits
- Employer-paid comprehensive medical, pharmacy, and dental insurance 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
- 401(k) Retirement Savings Plan
- Income Protection Insurance
- Vacation time
- Company celebrations
- Employee Referral Bonus
- Tuition reimbursement
- License Renewal CEU Cost Reimbursement Program
- Business-casual working environment
- Sick days
- Paid holidays
- Mileage
- Potential sign-on bonus and discretionary awards
- Parental leave
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What This Job Offers
Job Type
Full-time
Career Level
Director
