Pre-Authorization Unit Manager

About the role

Provides oversight of the Pre-Authorization unit to ensure all organization determinations are within regulatory compliance for time frames and notification parameters through ongoing monitoring of the unit’s activity.

Development and direct oversight of all MLTC/MAP organization determination/authorization processes to ensure timeliness and compliance with CMS/DOH regulations.

Collaborates in the development of goals, objectives, and performance measures and outcomes for the Coordinated Care Department.

Responsibilities

• Reviews and revises all workflows and policies for the Pre-Authorization unit on at least an annual basis to ensure compliance with DOH and CMS regulations.
• Communicates changes required for compliance within and outside of the Coordinated Care Department, including Member Operations, Customer Service, Claims, Compliance, and Appeals and Grievances departments.
• Ensures Interqual (IQ), internal policies, and other criteria (NYS DOH, NCD, LCD) are applied consistently among staff through daily monitoring and review of requests for services assigned to the unit.
• Educates staff on any changes to criteria or policy.
• Discusses with the Director the need for additional medical policy when gaps in coverage criteria are noted.
• Conducts periodic focused medical records reviews for the Pre-Authorization unit using department-specific audit tools and provides additional education as needed.
• Analyzes combined collected audit data and reports findings to Coordinated Care management.
• Works with the Staff Educator on retraining efforts either on-site or through Webinar sessions.