The purpose of the Care1st Health Plan Arizona, Inc. Prior Authorization Operations Supervisor is to be responsible for the day to day operations of the Prior Authorization Technicians and Notice of Action (NOA) staff. This position, plans, directs, supervises and helps to evaluate and coordinate work flow activities to achieve performance standards per AHCCCS and Medicare requirements and staff productivity. They recognize and recommend operational improvements and are responsible for development and/or updating of prior authorization policies and job aids. They work in conjunction with the clinical staff to ensure coordination between the teams.
• 5+ years experience in Prior Authorization operations in a managed care setting
• Experience in supervisory or managerial capacity
• Ability to interact with all levels of departmental and health plan staff with excellent written and verbal communication skills
• Computer literate (proficient in MS Office, Excel, Word)
• Must have previous AHCCCS health plan experience
• Knowledge of Medicare and NCQA
• Knowledge of Milliman Criteria
• Ability to interact with physicians, patients, and service providers using excellent customer service skills
• In-depth knowledge of local health care delivery systems and provider practice patterns for the Arizona market
• Proficient in ICD-9, CPT and HCPCS
ESSENTIAL DUTIES AND RESPONSIBILITIES:
• Oversee and supervise the Prior Authorization Department, which includes prior authorization, children rehabilitative services and notice of action staff
• Develop operational improvements to ensure service level goals and productivity is met.
• Facilitate the ongoing development and education of the prior authorization staff.
• Assist with completion and submission of prior authorization reports to regulators.
• Make recommendations for the departmental budget.
• Assist the coordination between the prior authorization and concurrent review departments to ensure timely and safe discharges.
• Delegate duties to staff to assure completion of departmental goals and objectives.
• Represent the department administratively.
• Participate in committees and administrative meetings as required.
• Attend AHCCCS meetings as required
• Work with Information Systems to develop appropriate reporting.
• Work with Information Systems on new software implementations.
• Identify potential quality issues and report these to Quality Management.
• Evaluate the effectiveness of prior authorization processes and implements changes to ensure optimal workflow, including meeting and/or exceeding plan turn around times and phone service requirements.
• Communicate effectively with providers.
• Monitor and update NOA processes to ensure NOA’s meet all regulator standards for timeframes and appropriate language levels.
• Contribute to the development and documentation of guidelines, job-aids, and policies and procedures.
• Perform all other duties as assigned.
• Understands and abides by all departmental policies and procedures as well as the organization’s Corporate Integrity Program.
• Attends mandatory Corporate Integrity Program education sessions, as required for this position, including the annual mandatory Standards of Conduct class.
• Participates actively in ensuring that all state and federal rules and regulations are followed as they apply to this position.
• Abides by all applicable laws and regulations as mandated by state and federal laws and prevents being excluded or sanctioned from any state and/or federal programs as they pertain to healthcare.
• Medical management decision making is based only on appropriateness of care and service and existence of coverage.
• We do not reward employees or other individuals for issuing denials of coverage of service or care.