Position Summary
The Director of Prior Authorization oversees non-clinical prior authorization staff, primarily coordinators, responsible for intake and review of pre-certification referrals. This role ensures quality, cost-effective utilization management and strict adherence to UM policies and procedures across affiliated medical groups. This is an ON-SITE, Full-time permanenet position located in West Hills, California.
Key Responsibilities
- Lead, coordinate, and manage prior authorization staff and daily operations
- Develop and maintain efficient workflows to meet compliance, timeliness, and customer service KPIs
- Support Medical Director program goals and organizational UM objectives
- Develop, refine, and implement utilization management policies and procedures aligned with industry standards and current literature
- Collaborate with medical leadership to interpret and administer applicable regulations, including CMS, DMHC, and HICE requirements
- Oversee quality assurance and continuous improvement initiatives related to processes, workflows, and patient-centered service delivery
- Compile and analyze operational data to prepare performance and compliance reports
- Represent the department in internal and external meetings and collaborate cross-functionally with clinical leadership and key stakeholders
Qualifications
- Management experience in utilization management or prior authorization operations
- Experience with staff supervision, program management, and issue resolution
- Strong knowledge of regulatory requirements including CMS, DMHC, and HICE UM standards
- RN preferred; ideal candidate will possess a clinical background with prior authorization or utilization management leadership experience
- Project management experience preferred