JOB SUMMARY

Responsible for leading, strategic planning, and overseeing the daily operations of the Preauthorization department. This pivotal role ensures that all medical services, procedures and pharmaceutical requests meet clinical necessities aligned with clinical guidelines, patient plan benefit package and other regulatory or contract requirements before care is delivered. Responsible for designing and implementing robust cost containment strategies to minimize financial risk and denials, while simultaneously driving high-performance standards across your team to optimize workflow efficiency and turnaround times.

ESSENTIAL FUNCTIONS

• Develop and execute cost containment strategies. Formulate and implement comprehensive strategies to minimize out-of-network utilization, reduce unnecessary medical expenditures, and prevent costly authorization denials.
• Payer & Policy Alignment. Stay ahead of shifting healthcare regulations, Medicare/Medicaid guidelines, and commercial payer policies to adapt preauthorization workflows, ensuring maximum reimbursement and minimal financial leakage.
• Analyze high-level utilization data, denial trends, and financial reports to identify areas of waste or operational bottlenecks, creating actionable plans to mitigate risks.
• Partner closely with Utilization Review (UR), Contracting, Billing, Clinical Leaders, Medical Groups, and other cross-functional teams to align preauthorization processes with broader corporate financial and clinical goals.
• Lead, motivate, and mentor a multidisciplinary team of preauthorization specialists, nurses, supervisors and managers.
• Define, monitor, and enforce clear Key Performance Indicators (KPIs) for the team, including first-pass authorization rates, turnaround times (TAT), denial rates, overturned rates, volume per categories and LOBs and individual productivity metrics.
• Conduct regular performance evaluations, construct targeted Performance Improvement Plans (PIPs) when necessary, and foster a culture of continuous learning and accountability.  Analyze workflows opportunities and establish action plans for improvements. 
• Oversee staffing models and workload distribution to ensure the department is appropriately staffed to handle fluctuating volumes without sacrificing quality or speed.
• Standardize and automate preauthorization workflows leveraging the latest healthcare technology, EHR systems, and AI-driven authorization tools for process optimizations.
• Ensure all preauthorization activities strictly adhere to state/federal regulations, NCQA (MOC), URAC, HIPAA and other Regulatory Organizations standards. Oversee internal auditing processes to guarantee documentation accuracy.
• Serve as the ultimate point of escalation for complex clinical cases, high-dollar peer-to-peer reviews, and expedited appeal processes.

EDUCATION

EXPERIENCE

Bachelor’s Degree in Healthcare Administration, Nursing, or a related field is required. (Master’s Degree/MHA preferred). At least five (5) years of progressive experience in prior authorization, utilization management, or healthcare revenue cycle management. At least three (3) years in a dedicated leadership or managerial role, overseeing large teams in a utilization management system, preferable at payer environment.

Active Clinical Licensure (RN, LVN/LPN, or NP) is highly preferred.

LICENSES AND CERTIFICATIONS

COMPETENCIES