Associate Manager, Clinical Quality (Prior Authorization)- Remote

About the role

It takes great medical minds to create powerful solutions that solve some of healthcare’s most complex challenges. Join us and put your expertise to work in ways you never imagined possible. We know you’ve honed your career in a fast-moving medical environment. While Gainwell operates with a sense of urgency, you’ll have the opportunity to work more flexible hours. And working at Gainwell carries its rewards. You’ll have an incredible opportunity to grow your career in a company that values work-life balance, continuous learning, and career development.

Responsibilities

• Supervise the Prior Authorization quality review program, including policies, procedures, and controls supporting compliance with standards, regulations, accreditation requirements, and contracts.
• Develop and maintain quality assurance processes, audit methodologies, and performance benchmarks for medical and behavioral health Prior Authorization reviews.
• Supervise and mentor clinical quality auditors and reviewers through education, coaching, and performance feedback.
• Monitor and report quality, accuracy, timeliness, productivity, denial rationale, and interrater reliability metrics.
• Identify trends, root causes, and improvement opportunities in clinical criteria application, documentation, review consistency, and workflows.
• Analyze audit results, appeals, complaints, and regulatory findings to identify issues and recommend corrective actions.
• Prepare reports and dashboards for leadership on performance, audit outcomes, risks,