Senior Manager, Prior Authorization - clinical license preferred

Position plans and directs activities and operations for prior authorization management in multiple markets, designed to achieve quality and service driven objectives.

DEPARTMENT: Health Services-Outpatient Services

REPORTS TO: Sr. Director, UM Strategy

Essential Functions:

  • Develops and directs optimal workflows to achieve successful quality outcomes and benefit maximization within the scope of responsibilities.
  • Serves as an instrumental partner in monitoring and tracking key performance indicators to include identification of over/under utilization patterns and/or deviation from expected results for assigned area/markets.
  • Provides leadership and support to front-line staff and supervisors.
  • Monitors and tracks production and quality driven work products and outcomes to individual performers.
  • Leads talent management activities to develop and cultivate future leaders.
  • Plans, conducts and directs work on complex projects/programs necessitating the origination and application of new and unique approaches.
  • Sets integration priorities, develops growth strategies, and manages resources for new business opportunities.
  • Develops processes and procedures to ensure department-wide compliance with contractual, regulatory (Federal/State) and accreditation entities.
  • Performs other duties as assigned.

Additional Responsibilities:

  • Represents Prior Authorization in meetings as needed.
Candidate Education:
  • Required a High School or GED
  • Preferred a Bachelor's Degree in Healthcare, Business Administration or similar field
Candidate Experience:
  • Required 7 years of experience in a combination of UM, operations and/or business related field
  • Required 3 years of management experience progressively responsible management
  • Required 3 years of experience in an operations environment
Candidate Skills:
  • Intermediate demonstrated problem solving skills
  • Intermediate demonstrated interpersonal/verbal communication skills
  • Intermediate knowledge of community, state and federal laws and resources
  • Intermediate ability to effectively present information and respond to questions from families, members, and providers
  • Intermediate ability to work within tight timeframes and meet strict deadlines
  • Intermediate demonstrated written communication skills
  • Intermediate ability to lead/manage others
  • Intermediate ability to communicate and make recommendations to upper management
  • Advanced solid understanding of managed care and its place in the healthcare industry.
  • Intermediate demonstrate effective critical thinking and decision making skills

Licenses and Certifications:

  • A clinical licensure is preferred.
Technical Skills:
  • Required intermediate Microsoft Word
  • Required intermediate Microsoft Excel
  • Required intermediate Microsoft PowerPoint
  • Required intermediate Microsoft Outlook
  • Required intermediate Healthcare Management Systems (Generic)

    About us
    Headquartered in Tampa, Fla., WellCare Health Plans, Inc. (NYSE: WCG) focuses primarily on providing government-sponsored managed care services to families, children, seniors and individuals with complex medical needs primarily through Medicaid, Medicare Advantage and Medicare Prescription Drug Plans, as well as individuals in the Health Insurance Marketplace. WellCare serves approximately 5.5 million members nationwide as of September 30, 2018. WellCare is a Fortune 500 company that employs nearly 12,000 associates across the country and was ranked a "World's Most Admired Company" in 2018 by Fortune magazine. For more information about WellCare, please visit the company's website at www.wellcare.com. EOE: All qualified applicants shall receive consideration for employment without regard to race, color, religion, creed, age, sex, pregnancy, veteran status, marital status, sexual orientation, gender identity or expression, national origin, ancestry, disability, genetic information, childbirth or related medical condition or other legally protected basis protected by applicable federal or state law except where a bona fide occupational qualification applies. Comprehensive Health Management, Inc. is an equal opportunity employer, M/F/D/V/SO.