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Clinical Nurse Supervisor Utilization Management
4 weeks ago
The Clinical Nurse Supervisor Utilization Management will oversee the department operations to ensure service standards are met. This role will make recommendations regarding assignments based on assessment of workload, serve as a resource to the Prior Authorization staff regarding CalOptima Health's policies and procedures, and regulatory requirements governing authorization processing. The incumbent will provide ongoing monitoring and development of staff.
Duties & Responsibilities:
Participates in a mission-driven culture of high-quality performance, with a member focus on customer service, consistency, dignity, and accountability. Assists the team in carrying out department responsibilities and collaborates with others to support short- and long-term goals/priorities for the department. Assists the manager as needed to ensure departmental and agency goals are met. Assists in the monitoring of appropriate benefit checks, application of guidelines to determine medical necessity, appropriate routing, and timely completion of authorization requests. Assists with the collection, monitoring, and analysis of prior authorization indicators and activities. Reviews workflows, procedures, and/or policies and recommends or implements changes as appropriate. Provides coverage and expertise for other teams within the Utilization Management department. Conducts prior authorization presentations to internal or external customers. Identifies new learning opportunities for staff and develops training materials to provide education. Serves as a subject matter expert to departmental staff, internal departments, and affiliated health networks regarding authorization rules and processes. Creates staffing assignments based on authorization priority, workload, current staffing, and review of timeliness reports. Performs interviews of potential candidates and makes recommendations for second-round interviews and/or hiring of a candidate. Trains, audits, supervises, and coaches Prior Authorization staff. Conducts performance feedback and/or counseling/corrective action meetings in collaboration with Human Resources as applicable. Identifies and conducts performance feedback and/or counseling/corrective action meetings with the assistance of Human Resources as necessary. Completes other projects and duties as assigned.
Experience & Education:
An Associate's degree in Nursing (ADN) is required. Current and unrestricted California Board Licensed Vocational Nurse (LVN) or Registered Nurse (RN) license is required. Three years of clinical nursing experience is required, preferably in a managed care environment. Two years of progressive leadership experience, including direct supervision of staff in managed care and/or utilization management, is required. One year of utilization management/prior authorization review experience is required. An equivalent combination of education and experience sufficient to successfully perform the essential duties of the position is also qualifying. Preferred qualifications include a Bachelor's degree in Nursing (BSN).
