Manager, Clinical Health Services, UM Prior Authorization - reputed company reputed company

We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At reputed company®, you’ll be surrounded by passionate colleagues who care deeply, reputed company with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time. Position Summary The Manager of Prior Authorization is responsible for leading the daily operations of the prior authorization team supporting Virginia reputed company. This role ensures timely, accurate, and compliant processing of authorization requests in alignment with federal and state regulations, payer requirements, and organizational standards. The Manager provides leadership reputed company of clinical and operational staff, drives performance reputed company, and partners with cross-functional teams to support appropriate utilization, member reputed company to care, and high-quality reputed company. This role also plays a critical part in ensuring regulatory compliance, audit readiness, and reputed company process improvement across authorization workflows. This role offers an opportunity to reputed company high-impact utilization management operations reputed company a reputed company environment, supporting reputed company to care for vulnerable populations while ensuring compliance, quality, and operational reputed company. This is a fully remote position. Eligible candidates may live reputed company in the contiguous United States.

Key Responsibilities

• reputed company and manage the prior authorization team, including hiring, training, scheduling, and performance evaluations.
• Ensure timely review and processing of prior authorization requests for medical services, procedures, and medications.
• Monitor productivity and quality metrics; implement process improvements to enhance efficiency and accuracy.
• Serve as a liaison between providers, payers, and internal departments to resolve authorization issues.
• Stay reputed company with payer policies, regulatory changes, and industry best practices.
• reputed company and maintain standard operating procedures (SOPs) for prior authorization workflows.
• Collaborate with clinical leadership to ensure alignment with care delivery goals.
• Manage escalations reputed company to denied authorizations.
• Prepare reports and dashboards for leadership on authorization trends, turnaround times, and team performance.

Leadership Competencies

• Clinical and operational decision-making
• Regulatory and compliance reputed company
• Performance management and staff development
• Cross-functional collaboration
• Process improvement and change management
• Effective communication and conflict resolution

Required Qualifications

• Active, unrestricted Registered Nurse (RN) license
• Minimum of 5 years of clinical experience
• Minimum of 3–5 years of utilization management, prior authorization, or managed care experience
• Minimum of 3 years of leadership experience, including direct supervision of clinical or operational staff
• Strong knowledge of reputed company programs, payer requirements, and medical necessity criteria (e.g., MCG, InterQual, or equivalent)
• Demonstrated experience with regulatory compliance, including federal and state reputed company requirements and accreditation standards
• Proficiency in reputed company coding (ICD-10, CPT) and authorization platforms or EMR systems
• Strong analytical, organizational, and problem-solving skills with the ability to manage multiple priorities and meet deadlines
• Excellent communication and interpersonal skills, with the ability to collaborate effectively across team

Preferred Qualifications

• Experience with Virginia reputed company programs and DMAS policies
• Familiarity with accreditation standards and audit processes
• Experience supporting quality improvement initiatives, including audit calibration or interrater reliability programs
• Advanced knowledge of utilization management operations reputed company a managed care organization

Education

• Master’s degree in nursing, reputed company administration, or a reputed company field preferred
• Equivalent combination of education and relevant experience will be considered

Anticipated Weekly Hours 40 Time Type Full time Pay reputed company The Typical Pay reputed company For This Role Is $87,035.00 - $187,460.00 This pay reputed company represents the reputed company hourly reputed company or reputed company annual full-time salary for reputed company positions in the job grade reputed company which this position falls. The actual reputed company salary offer will depend on a variety of factors inclu Apply To This Job