Pre Cert RN Manager

POSITION DUTIES & RESPONSIBILITIES

• Lead and support the Prior Authorization Supervisor and nursing staff to ensure effective daily department operations.
• Assist in supporting and providing general oversight of Prior Authorization Coordinators – who report directly to Prior Auth Supervisor.
• Serves as the escalation point for complex prior authorization requests or operational concerns.
• Oversee staffing, performance, workflow optimization, and workload distribution across clinical and non-clinical roles.
• Facilitate departmental huddles, 1:1 meetings, and team training in partnership with the PA leadership.

COMPLIANCE & QUALITY ASSURANCE

• Monitor and manage turnaround time compliance for Routine/Standard and Urgent/Expedited PA requests according to CMS, NCQA, and contractual standards.
• Conduct monthly internal audits of staff performance and documentation accuracy; provide coaching and feedback to maintain quality standards (98%+ accuracy goal).
• Ensure timely and accurate submission of internal and external utilization management (UM) reports and audit data.

PROCESS IMPROVEMENT & REPORTING

• Analyze trends in prior auth denials, delays, and workload bottlenecks; propose and implement corrective actions.
• Lead or support process documentation, including SOP reviews, workflow changes, and performance metric tracking.
• Coordinate semi-annual underutilization review and contribute to the development of the UM Work Plan for executive leadership.

STAKEHOLDER ENGAGEMENT

• Acts as a liaison between the PA Team, Medical Directors, office staff, and physicians to resolve PA-related issues and promote collaboration.
• Provide ongoing training and mentorship to new hires and existing staff, emphasizing customer service, regulatory compliance, and AZPC policies.
• Support the Director of Clinical Services Operations in preparation for audits by CMS, health plans, or NCQA.

EDUCATION, TRAINING AND EXPERIENCE

• Graduated from an accredited Registered Nurse (RN) Program.
• Current, unrestricted RN License in the State of Arizona.
• 5+ years of experience in Utilization Management with comprehensive knowledge of prior authorization processes.
• 3+ years of leadership or supervisory experience in a healthcare, managed care, or payer environment.
• Strong understanding of Medicare, Medicaid, and state/federal managed care regulations, including NCQA Utilization Management standards.
• Strong working knowledge of Medicare, state and federal managed care regulations, and NCQA guidelines.
• Proven ability to communicate clearly and professionally in both verbal and written formats – critical for coordinating across clinical teams, providers and payers.
• Demonstrated attention to detail and documentation accuracy, especially important for regulatory compliance and audit preparedness.
• Strong analytical and problem-solving skills to identify workflow gaps and implement effective process improvements.
• Able to prioritize and manage competing tasks in a high-volume environment with minimal supervision.
• Proficient in Microsoft Office tools (Outlook, Word, Excel, PowerPoint) and experienced with electronic health record (EHR) and prior authorization systems.

COMPENSATION RANGE

The annual range for this position is: $96,000 – $100,000