Director, Prior Authorization

Job ID: J108896
Location: Pittsburgh, PA, United States
Full/Part Time: Full time
Job Type: Regular
Posted at: Sep 29, 2017

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Description

JOB SUMMARY

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.

ESSENTIAL RESPONSIBILITIES

  • Performs management responsibilities including, but not limited to: hiring and termination decisions, coaching and development, rewards and recognition, performance management and staff productivity management.
  • Plans, organizes, staffs, directs and controls the day-to-day operations of the department; develops and implements policies and programs as necessary; may have budgetary responsibility and authority.
  • Ensures uniform core competencies among utilization management staff through ongoing training, education, inter-rater reliability testing, and performance monitoring, including a continual focus on the correct, efficient and thorough application of InterQual criteria and/or Milliman Care Guidelines (as applicable) and utilization of applicable software applications/tools to the fullest extent possible.
  • Performs strategic planning for the department; accountable for the operational excellence of the unit, control of administrative and care cost initiatives, system development and delivery of high quality outcomes, compliance with all state and federal regulations that affect utilization management activities and any needed reporting in a complete and timely manner.
  • Develops  and periodically evaluates administrative policies and procedures for the area and reviews the policies and procedures at least on an annual basis.  Ensures that utilization management requests are handled at the most appropriate staff level.
  • Monitors, reports and controls departmental activities to optimize efficiency and effectiveness and improve outcomes for members.
  • Maintains current knowledge of applicable CMS, state, local, and regulatory agency requirements and standards related to utilization management/utilization review or other areas of responsibility.
  • Other duties as assigned or requested.

REQUIRED EDUCATION

Bachelor's Degree- Nursing

PREFERRED EDUCATION

Nursing, Business or Healthcare related field

EXPERIENCE

Minimum:

  • 7-10 years' of health care-related experience which must include at least 3 years' of recent managerial experience at a manager level or higher in an operations environment
  • 5 years' minimum experience in utilization management or utilization review

Preferred:

  • Certification in case management or utilization management
  • Prior clinical experience in a variety of settings including a mixture of provider-based and payer-based positions

KNOWLEDGE, SKILLS & ABILITIES

  • Strategic thinking skills
  • Excellent written and verbal communication skills
  • Extensive knowledge of utilization management/utilization review in a payer-based or health plan environment
  • Ability to analyze data, measure outcomes and develop and implement action plans
  • Computer literacy and knowledge of utilization management software applications and basic office applications such as Excel, Word, PowerPoint, etc.
  • Demonstrated proficiency in customer service skills and highly effective interpersonal skills
  • Demonstrated effective leadership and managerial skills
  • Demonstrated ability to be a change agent

REQUIRED LICENSURE

  • Active RN Licensure - PA

Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities, and prohibit discrimination against all individuals based on their race, color, religion, sex, national origin, sexual orientation/gender identity or any other category protected by applicable federal, state or local law. Highmark Health and its affiliates take affirmative action to employ and advance in employment individuals without regard to race, color, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability.
EEO is The Law
Equal Opportunity Employer Minorities/Women/ProtectedVeterans/Disabled/Sexual Orientation/Gender Identity (http://www1.eeoc.gov/employers/upload/eeoc_self_print_poster.pdf)
We endeavor to make this site accessible to any and all users. If you would like to contact us regarding the accessibility of our website or need assistance completing the application process, please contact number below.
For accommodation requests, please call HR Services at 844-242-HR4U or visit HR Services Online at HRServices@highmarkhealth.org

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