Job ID: J108896
Location: Pittsburgh, PA, United States
Full/Part Time: Full time
Job Type: Regular
Posted at: Sep 29, 2017
This job leads and directs the organization's prior authorization processes and functions relative to outpatient procedures, durable medical equipment (DME), home health, and planned acute-care inpatient admissions. This includes leading/managing three teams of nurses including the Medicare Advantage team, the commercial special groups team, and the commercial other team, in addition to the non-clinical intake staff and the administrative support staff. This job requires expertise in the areas of utilization management, benefit interpretation, insurance industry regulations/compliance standards and personnel management. The leader is accountable for the operational excellence of the prior authorization unit, control of administrative costs, care cost initiatives, system development, delivery of high quality outcomes, compliance with all state and federal regulations that affect utilization management (UM) activities and any needed reporting in a complete and timely manner. The leader is ultimately responsible for compliance with NCQA, URAC, CMS, DOH and DOL regulations as related to utilization management activities and for ensuring an exceptional customer experience that facilitates appropriate resource utilization in the most appropriate care setting.
Bachelor's Degree- Nursing
Nursing, Business or Healthcare related field
KNOWLEDGE, SKILLS & ABILITIES
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