RN Manager of Prior Authorization – Health Plan
North Seattle, WA (Northern Suburb near Lynwood)
Manager of Prior Authorization Job Summary:
Manager of Prior Authorization Background:
- RN Manager of Prior Authorization / Utilization Management is to promote the quality and cost effectiveness of prior authorization requests; may assist with concurrent and retrospective review functions, if needed.
- This person is responsible for management and oversight of daily managerial operations pertaining to pre-certification; including but not limited to training, development of process and quality review programs.
- The Manager assists with daily management of staff, auditing functions, and assuring that all staff provides a level of customer service that meets or exceeds the organization’s expectations.
- Understand, promote and audit the principles of Utilization Management to facilitate the right care at the right time in the right setting.
- Communicate effectively and interact with the medical directors, hospitalists, provider offices, staff and health plans daily or as indicated regarding UM and referral authorization issues.
- Verify that the following processes are communicated to the Utilization Management Staff and are being followed by conducting monthly audits of the staff’s production:
- Member benefits are being checked, and denial process is clear
- Process for collecting data for deferred referrals as well as urgent/stat referrals
- Staff is compliant with turnaround times for all statuses
- Valid, unrestricted state Registered Nurse (R.N.) license
- Prefer Bachelor of Science in Nursing (B.S.N.) or related field; Master’s degree a plus.
- Certification in Case, Utilization, or Quality Management, such as CCM, CPUM/CPUR/CPHM, or CPHQ, is preferred.
- Roughly 3-5 years of acute care clinical nursing experience.
- At least 5 years of Utilization Management / Utilization Review / Care Coordination experience, including at least 2 years of experience at a health plan or other managed care organization (HMO/TPA/IPA/etc).
- Requires 2 years of healthcare or health plan supervisory or managerial experience, including oversight of clinical staff.
- Extensive knowledge of Medicare, Medicaid and similar state health programs, their regulatory guidelines, benefit management and coverage determination, reconsideration, and appeal processes.
- Experience in training / teaching staffs to meet operational requirements and goals.
- Strong oral and written communication skills; ability to interact with all levels of internal and external contacts.