Job Description

The Director, Prior Authorization will be responsible for development of and maintenance of Prior Authorization and Denial Compliance Job Aids, Work Flows, procedures & related documents and ensuring alignment with HPN and regulatory Policies and guidance in compliance with DMHC, DHCS, CMS & NCQA requirements, as well as Health Plan contractual obligations. This role will develops & maintain Prior Authorization training related to Prior Authorization and identify best practices and process improvements based on internal, health plan, regulatory, and HPN audits/reviews. The role will develops tools to assist the Prior Authorization management and staff in implementing new or updated Policies & Procedures, in addition reviews results provided by HPN and internal oversight audits and monitoring mechanisms and develops tools and aids to assist Prior Authorization in improving compliance and service results.

In collaboration with colleagues, the Director is also responsible for the development of job aids & work flows as well as training materials (Presentation, delivery, tips, etc.) to assist in improving the performance and consistency of the Prior Authorization functions. Develops easily accessible and usable employee resource center for Prior Authorization job aids, training materials and other employee resources to support optimized work processes, excellent compliance and service results.

As a member of the Prior Authorization management team, this person will attend leadership and management meetings, interface directly with the Medical Management, (UM & CM), Customer Service, Pharmacy, Compliance, Claims and other leaders and health plan representatives as required related to Prior Authorization training, job aids, work flows and processes.

The Director, Prior Authorization coordinates, plans and manages staff activities; develops with Medical Director program goals and objectives; makes staff assignments; develops or assists in the development of related prior authorization and claims policy, incorporating current literature and professionally recognized standards; develops or assists in development and implementation of policy and plans for effective patient centered utilization management; together with the medical director, interprets and administers pertinent laws; through direct and indirect contact, evaluates staff and determines the quality of their work efforts; develops and/or implements effective ongoing programs to measure, assess and improve quality of processes and workflows, treatment and services delivered to patients; develops productive work teams; recommends disciplinary actions; collaborates with clinical leadership for educational programs; represents the department in meetings of professional and/or community organizations; compiles data and prepares periodic reports; responsible for coordinating and providing appropriate coverage; maintains contacts with individuals both within and outside of the department who might impact on program activities; assures optimal quality of care and service is provided; participates in Quality Assurance Programs as needed; intervenes in crisis situations and investigates all unusual incidents; leads and participates in meetings; may speak on behalf of department. This position requires general knowledge of CMS and ICE UM processes/policies/procedures and timeliness standards and management level experience including but not limited to: staff oversight, program management, and issue resolution.

Essential Duties and Responsibilities include the following:

1. Develops, updates and maintains Prior Authorization Job Aids, procedures, program descriptions and related documents in compliance with DMHC, DHCS, CMS & NCQA requirements, as well as Health Plan contractual requirements, HPN Policies and direction from Compliance.
2. Develops a process to keep up to date on regulatory and accreditation changes as well new and modified HPN policies and uses this information to proactively update trainings, job aids, and other helpful tools for Prior Authorization.
3. Develops feedback mechanisms to ensure work being performed is delivering on needed results – i.e., meeting/exceeding compliance and service requirements.
4. Develops, updates and maintains Prior Authorization compliance and procedural related training courses.
5. Presents trainings in webinars or in-person as appropriate or needed.
6. Reviews audit results (CQM, internal, HPN, health plans, regulatory, others) to review trends and collaboratively works with Prior Authorization management to develop the tools, trainings, job aids, communication tips, to support improved results as measured by audits and customer feedback.
7. Develops, updates and maintains training materials to support Prior Authorization policies, procedures and job aids.
8. Collaborates with PA leadership, Compliance, HPN, others to obtain consensus on job aids that are compliant with Policies and Procedures.
9. Develops, updates and maintains job aids, workflows and training materials to improve the performance and consistency of Prior Authorization and develops an easily accessible staff resource center for PA.
10. Identifies opportunities to improve quality, increase productivity and improve cycle time by reducing wasted time, errors, and rework resulting in business improvement.
11. Works closely with Subject Matter Experts (SMEs) and process owners to successfully manage project timelines, progress reporting, recommendations, and implementation plans.
12. Work with Decision Support to create automated auditing process for critical data elements when appropriate.
13. Provide leadership with project status updates, feedback, and appropriate reporting on key responsibilities and objectives.
14. Makes recommendations for improvements in systems, work process, job aids to improve the quality and productivity of the team.
15. Develops positive customer relationships.
16. Communicates effectively and interacts with the department managers, compliance officer, RMD and staff regarding all medical management processes.
17. Participates in the quality monitoring and review process.
18. All other duties as directed by management.

The pay range for this position at commencement of employment is expected to be between $140,000 annually - $150,000 annually for RN; however, base pay offered may vary depending on multiple individualized factors, including market location, job-related knowledge, licensure, skills, and experience. This position also offers a sign on bonus. Sign on bonus differs based on medical license LVN $7, 000 or RN $10,000.

The total compensation package for this position may also include other elements, including a sign-on bonus and discretionary awards in addition to a full range of medical, financial, and/or other benefits (including 401(k) eligibility and various paid time off benefits, such as vacation, sick time, and parental leave), dependent on the position offered.

Details of participation in these benefit plans will be provided if an employee receives an offer of employment.

If hired, employee will be in an “at-will position” and the Company reserves the right to modify base salary (as well as any other discretionary payment or compensation program) at any time, including for reasons related to individual performance, Company or individual department/team performance, and market factors.

As one of the fastest growing Independent Physician Associations in Southern California, Regal Medical Group, Lakeside Community Healthcare & Affiliated Doctors of Orange County, offers a fast-paced, exciting, welcoming and supportive work environment. Opportunities abound, and enterprising, capable, focused people prosper with us. We promote teamwork, nurture learning, and encourage advancement for all of our employees. We want to see you excel, because we believe that your success is our success.

Full Time Position Benefits:

The success of any company depends on its employees. For us, employee satisfaction is crucial not only to the well-being of our organization, but also to the health and wellness of our members. As such, we are firmly dedicated to providing our employees the options and resources necessary for building security and maintaining a healthy balance between work and life.

Our dedication to our staff is evident in our comprehensive benefits package. We offer a very generous mixture of benefits, including many employer-paid options.

Health and Wellness:

• Employer-paid comprehensive medical, pharmacy, and dental for employees
• Vision insurance
• Zero co-payments for employed physician office visits
• Flexible Spending Account (FSA)
• Employer-Paid Life Insurance
• Employee Assistance Program (EAP)
• Behavioral Health Services

Savings and Retirement:

• 401k Retirement Savings Plan
• Income Protection Insurance

Other Benefits:

• Vacation Time
• Company celebrations
• Employee Assistance Program
• Employee Referral Bonus
• Tuition Reimbursement
• License Renewal CEU Cost Reimbursement Program
• Business-casual working environment
• Sick days
• Paid holidays
• Mileage

Employer will consider for employment qualified applicants with criminal histories in a manner consistent with the requirements of the LA City Fair Chance Initiative for Hiring Ordinance.

Qualifications

Education and/or Experience:

1. Preferred - Graduate from an accredited Registered Nursing Program with current/active RN license. If appropriate based on the candidate, an LVN may be considered.
2. Five years of progressive prior-authorization experience or related experience in a medical group, IPA or Management Company required, with Medical Management and Claims experience recommended.
3. Project Management experience a plus.
4. Prior experience with project development and implementation, and have excellent organizational, interpersonal and analytical skills.
5. Experience supervising staff and monitoring productivity/performance required.
6. Must have excellent communications skills both verbally and written.
7. Ability to deal with responsibility with confidential matters.
8. Must be able to handle multiple projects at one time in a high stress environment, reset priorities day-to-day to meet deadlines, and know when to ask for assistance and direction when working with conflicting priorities.
9. Must be self-motivated, pleasantly aggressive and realistically ambitious and have high personal ethics.
10. Must have the ability to work with all levels of management and have the ability to develop positive working relationships with health plan auditors and company department heads.
11. Must have working knowledge of MS Office environment, and ability to function in highly computerized environment.
12. Requires current CA driver’s license and car insurance.