Submission for the position: Supervisor, Prior Authorization - (Job Number: 1192969)
https://centene.taleo.net/careersection/jobdetail.ftl?job=1192969&lang=en
Supervisor, Prior Authorization
Position Purpose:
Oversees the utilization management activities of outpatient review staff by evaluating the necessity and efficiency of services through systematic monitoring of medical necessity and quality, while maximizing the appropriate level of care that correlates to the member's benefit plan.
Essential Functions:
• Ensures that staff reviews and collects medical information in order to determine the medical necessity of services requested by applying specific medical criteria.
• Monitors staff work product to ensure that services provided to eligible members are within benefit plan, and appropriate contracted providers are being utilized.
• Ensures that staff initiates and continues direct communication with health care providers involved with the care of the member to obtain complete and accurate information.
• Ensures that staff identify appropriate clinical settings for services being requested.
• Ensures that staff identify and refer cases appropriate for case management.
• Ensures that staff identify potential quality of care issues and refers to Quality Department.
• Determines appropriate utilization management of services requested and ensures that staff are able to do same.
• Assists with implementation of health care initiatives in market.
• Assists in the implementation of specific strategies that improve the quality and outcomes of care.
• Acts as a subject matter expert within the team.
• Handles escalated issues at management's request.
• Acts as a team educator on new processes and/or policies.
• Performs and represents department and clinical duties at the request of management.
• Reviews and collects data to identify patterns and trends for member service utilization.
• Trains and mentors staff to ensure compliance with departmental regulations, policies and procedures.
• Provides direct supervision to outpatient care staff.
• Performs other duties as assigned.Additional Responsibilities:
Education/Experience:
• Preferred a Bachelor's Degree in a related field
• Required 4 years of experience in an acute clinical/surgical position(s), current experience in utilization management to include pre-authorization, utilization review, concurrent review, discharge planning, and/or skilled nursing facility reviews.
• Preferred Care management experience in a managed health care setting
Licenses and Certifications:
• Required Licensed Practical Nurse (LPN)
Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law.
Clinical & Nursing
USA-Florida-Tampa
Schedule: Full-time Location(s): USA-Florida-Tampa