Website Arizona Priority Care
Arizona Priority Care (AZPC) is an Integrated Provider Network focused on providing Whole-Person care to Senior and Medicaid populations, through advanced value-based models. Our provider network is comprised of more than 3,500 providers including Primary Care, Specialty, Hospital System and ancillary provider partnerships. We have operated in the Arizona market for more than 10 years, and are based in Chandler, Arizona. As a leading value-based provider organization, we are committed to improving the quality of care, providing excellent member and provider experiences all while reducing cost.
The Prior Authorization (PA) Manager is responsible for overseeing and managing the daily operations of the PA Department. Ensuring AZPC policies and procedures and regulatory guidelines are followed and met. Through daily management and participation in day-to-day activities, makes certain all prior auth staff provide outstanding customer service, are knowledgeable, and have the ability to assist in the coordination of care that meet or exceed the organization’s expectations. Works closely with PA leadership, PA staff, and Director of Credentialing & Prior Auth, as well as the Medical Directors to maintain turnaround time requirements of the contracted Health Plan(s), Center of Medicare and Medicaid Services (CMS), National Committee for Quality Assurance (NCQA) and internal targets. Routinely interacts with physicians, their office staff, and members.
POSITION DUTIES & RESPONSIBILITIES
- Provides direct oversight of all personnel within the PA Department and acts as direct point of contact for all questions and concerns.
- Manages the PA Department workflow to ensure that Routine/Standard and Urgent/Expedited requests are compliant with regulatory and health plan requirements.
- Knowledge of the daily operations and all duties performed by the PA Department.
- Performs monthly internal audits of PA staff to ensure quality of work being completed and provides constructive feedback and positive reinforcement in monthly 1:1 meeting.
- Conducts analysis to identify either process or individual staff performance barriers, implement interventions, and provide feedback to leadership or staff to correct deficiencies.
- Consults with the Department Director regarding staff performance issues.
- Provides support to the PA Nurses when needed and completes PA Nurse tasks with a minimum accuracy rate of 98%.
- Conduct new hire and ongoing training, coaching, and mentoring of PA staff on customer service standards, AZPC policies and procedures.
- Participates in collaboration with PA leadership to conduct huddles and department meetings to share updates, changes, and answer questions.
- Serves as a liaison between the Medical Director, physicians, and office staff in resolving prior authorization issues and problems/questions.
- Performs semi-annual review of underutilization of authorizations.
- Conduct final reviews of PA Department related Standard Operating Procedures.
- Ensures that all internal and external UM Preservice related reporting requirements are compiled and submitted timely and accurately.
- Participates in health plan and regulatory audits.
- Assists the Department Director in Health Plan and NCQA audit preparation, as needed.
- Has current knowledge of all health plan contracts, including but not limited to HMO, PPO, Private, Medicaid and Medicare.
- Other duties as assigned.
EDUCATION, TRAINING AND EXPERIENCE
- Graduated from an accredited Registered Nurse Program.
- Current unrestricted AZ RN License.
- Minimum of five (5) years’ experience with current working knowledge of Utilization Management concepts and the prior authorization processes, required.
- Minimum of three (3) years in a leadership role, required.
- Knowledge of Medicare, state, and local managed care regulations including NCQA Guidelines.
- Able to communicate verbally or in writing effectively and in professional manner with all levels of internal staff and external customers.
- Ability to work well both independently and as a part of a team, with minimal supervision under pressure.
- Excellent in detail orientation, critical thinking and problem-solving skills.
- Proficient ability with multiple Microsoft applications (Outlook, Word, Excel, PowerPoint, etc.) and work within electronic health records systems.
*This role requires FT in-office presence for the first 90 days of employment. Hybrid schedule available after initial training period.*
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