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Clinical Authorization Supervisor
2 months ago
Alliant Health Solutions, Inc. is a collective of organizations dedicated to enhancing the administration of healthcare programs and initiatives aimed at improving health outcomes. Our mission is to provide governmental entities with essential services, expertise, and information systems that elevate the quality, accessibility, and value of healthcare.
We are currently seeking a Supervisor for our PA/UM Department. This role encompasses a dual function, primarily focusing on overseeing a team of both clinical and non-clinical personnel. The Supervisor is responsible for delivering training and support tailored to specific review types, as well as conducting Prior Authorization and Precertification Reviews.
Key Responsibilities:
- Conduct evaluations of provider prior approval and precertification requests, including those for inpatient and outpatient facilities.
- Assess initial clinical data and authorize cases that meet established criteria, ensuring clear documentation of the rationale for all decisions based on appropriate guidelines or clinical judgment.
- Direct cases that do not meet criteria to a Referral Nurse Coordinator for further evaluation by a Peer Review Consultant.
- Engage with the Manager of PA/UM or Medical Directors regarding Peer Consultant review decisions or cases needing physician input.
- Uphold the confidentiality of review information and medical records in compliance with HIPAA regulations and company policies.
- Achieve team objectives by clearly communicating job expectations, monitoring performance, and providing coaching and counseling to staff.
- Participate in quality enhancement and peer review initiatives, including performance evaluations for new hires and annual assessments.
- Oversee team-specific Prior Authorization types to ensure compliance with contractual obligations.
- Develop and manage team assignments to guarantee the accuracy and timeliness of medical reviews, adhering to established clinical criteria and regulatory guidelines.
- Ensure that each reviewer is well-versed in various review types and the relevant policy manuals.
- Assist review staff in decision-making, problem identification, and resolution.
- Orient and train new employees on their responsibilities and may provide education on process updates and quality standards.
- Perform additional duties as required.
Additional Responsibilities:
- Collaborate closely with team members to foster the development of new projects and enhance overall team performance.
- Emphasize core values such as teamwork, professionalism, effective communication, and a positive work environment.
- Ensure the security and confidentiality of all information in accordance with HIPAA laws and organizational policies.
- Demonstrate adherence to corporate and departmental policies, including attendance and professional appearance.
- Execute other tasks and responsibilities as assigned.
Qualifications:
- In-depth knowledge of URAC, NCQA, or other quality accreditation standards.
- Familiarity with ICD-9-CM, CPT codes, and InterQual criteria is preferred.
- Management experience or demonstrated leadership in current role is required.
- Advanced clinical knowledge and problem-solving capabilities.
- Ability to work independently, employing creative thinking and thorough analysis for problem resolution.
- Strong time management skills with the ability to prioritize and organize tasks effectively.
- Proficient in computer skills, including typing at least thirty-five words per minute.
- Excellent interpersonal, written, and verbal communication skills.
- Commitment to maintaining confidentiality in accordance with HIPAA regulations and company policies.
- Willingness to travel as necessary.
Education and Experience:
Required:
- Registered Nurse with three to five years of recent clinical experience.
- Current nursing license in Georgia.
- Experience in referral coordination, utilization management, nurse reviewing, or prior approval processes.
Preferred:
- Bachelor's degree in nursing.
- Previous experience in a team lead, preceptor, or supervisory capacity.
Alliant Health Solutions, Inc. offers a balanced work-life environment and comprehensive benefits, including medical, dental, life insurance, disability coverage, paid time off, retirement plans with matching contributions, and an employee assistance program.
