Prior Authorization Manager

Keystone Advisors is looking for a Prior Authorization Manager to join our team in Chicago, IL supporting one of our healthcare clients in the Illinois Medical District.

Job Summary:

The Prior Authorization Manager supervises, consults, and guides prior authorization staff responsible for responding to all prior authorization requests. The Prior Authorization Manager ensures all requests are complete to include inpatient, outpatient, procedures, and therapies in accordance with best practices, Cook County Health (CCH) Policies and Procedures and Health Plan standards. The Prior Authorization Manager ensures all documentation is obtained to support level of care, medical appropriateness, and authorization.

Job Duties include but are not limited to the following:

• Develop and maintain a standardized prior authorization process to support departmental goals, to meet payer requirements, and support the achievement of CCH quality and cost objectives.
• Manage the compilation, analysis and reporting of data/metrics in support of continuous improvement in processes and operations.
• Monitor all Medicare and Medicaid Rules and Regulations, Medicare Conditions of Participation (CoPs), reimbursement methodologies, and Managed Care Organization (MCO) requirements and adjusts operations to meet changes.
• Distribute and delegate assignments to staff. Establishes competency measures for each staff member.
• Collect, monitor, evaluate, and communicate resource utilization and program metrics to support process and improvement and inform stakeholders.
• Identify variances in approval or denial patterns and collaborates with clinical departments to develop an action plan.
• Maintain current knowledge of regulatory guidelines, a thorough understanding of a managed care contract’s authorization requirements and Milliman Criteria.
• Maintain a close working relationship with contracted Health Plans, updating/educating client’s staff and providers on authorization policies and procedures.
• Create scheduling and completion of all pre-authorization/ referrals in accordance with managed care payer policy as detailed in payer provider manual.
• Attend and participate in meetings.
• Support client’s committees and workgroups as assigned.
• Perform related duties as necessary.

Minimum Qualifications:

• Bachelor’s degree from an accredited college or university
• Three (3) years of experience with health plans and following insurance processes
• Two (2) years payer or prior authorization experience
• Two (2) years of supervisory or managerial experience
• Proficiency using Microsoft Office (Word, PowerPoint, Excel)

Preferred Qualifications:

• Bachelor’s degree or higher in Health Care Administration, Organizational Development, Finance, or Accounting from accredited college or university
• Experience with InterQual or Milliman guidelines

Knowledge, Skills, Abilities and Other Characteristics:

• In-depth knowledge of health care delivery systems-Illinois Medicaid, Medicare/Medicaid and services provided my managed care companies
• Knowledge of InterQual or Milliman criteria set
• Thorough knowledge and understanding of the Health Insurance Portability and Accountability Act (HIPAA) to ensure the protection of the confidentiality and security of healthcare information for all patients
• Knowledge of Microsoft Office, Managed Care and Clinical Integration
• Excellent communication, supervisory and organizational skills
• Analytical skills necessary to review contracts and identify contractual requirements Ability to establish and maintain effective and cooperative working relationships with internal/external customers
• Strong background in prior authorization, ICD Coding, claims/benefits
• Skilled in the use of Microsoft Word, Excel, and Outlook
• Ability to work independently and make sound judgments under minimal supervision
• Ability to prioritize, plan, and organize projects and tasks
• Ability to multi-task and meet deadlines in a fast paced and stressful environment
• Strong attention to detail
• Strong initiative

Compensation Package:

• Competitive Salary
• Paid Time Off
• Health, Vision & Dental Insurance
• Health Savings Account (HSA)
• Flexible Spending Account (FSA)
• Short & Long Term Disability
• 401 (K) with company match
• Life Insurance