Associate Manager, Clinical Quality – Prior Authorization

This is a fully remote position, open to applicants in Florida.

📋 Description

• Oversee the quality review program for Prior Authorization, which includes policies, procedures, and compliance measures.

• Create and sustain quality assurance processes, audit methodologies, and performance benchmarks pertaining to medical and behavioral health Prior Authorization evaluations.

• Guide and mentor clinical quality auditors and reviewers through education, coaching, and feedback on performance.

• Track and report on quality, accuracy, timeliness, productivity, denial rationale, and interrater reliability metrics.

• Detect trends, root causes, and opportunities for improvement in clinical criteria application, documentation, review consistency, and workflows.

• Examine audit results, appeals, complaints, and regulatory findings to pinpoint issues and suggest corrective actions.

• Compile reports and dashboards for leadership that cover performance, audit results, risks, and improvement initiatives.

• Ensure that Prior Authorization reviews are conducted accurately, consistently, and within designated timeframes.

• Develop and provide training based on audit outcomes, policy updates, and performance trends.

• Stay informed about CMS, Medicaid, accreditation standards, clinical policies, and industry practices.

• Spearhead quality improvement initiatives aimed at enhancing accuracy, consistency, efficiency, and the experiences of both providers and members.

• Act as a subject matter expert for new tools, automation, operational readiness, and escalated quality concerns.

• Oversee individual and team performance to achieve or surpass performance standards.

• Execute additional duties as assigned.

⛳️ Requirements

• An associate degree is required; a bachelor’s degree is preferred.

• A current, unrestricted RN license is mandatory.

• Additional certifications in utilization management, case management, or healthcare quality are preferred.

• Familiarity with Prior Authorization, utilization management, medical necessity review, adverse determination processes, and relevant regulatory and accreditation standards.

• Capability to consistently and accurately apply evidence-based clinical criteria, health plan policies, benefit requirements, and clinical judgment.

• A minimum of 5 years of experience in Prior Authorization, utilization management, clinical review, or healthcare quality assurance.

• At least 2 years of leadership or quality assurance experience in a health plan, managed care, utilization management, or healthcare environment.

• Strong analytical, communication, coaching, and problem-solving abilities.

• Proficient in utilizing quality data to drive measurable improvements.

🏝️ Benefits

• Flexible hours and work arrangements.

• Work-life balance.

• Opportunities for continuous learning and career advancement.

• Flexible vacation policy.

• 401(k) employer matching.

• Comprehensive health benefits.

• Educational assistance.

• Leadership and technical development academies.

• Up to 20% travel.