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WellCare - Nursing Careers

Director, Prior Authorization Operations Job

Full Job Title: Director, Prior Authorization Operations

Job Number: 1706007

Location: Tampa, FL

Date Posted: 12-22-2017

Accountable for providing vision and strategy for inpatient utilization and prior authorization management activities designed to achieve quality and service-driven objectives. Oversees all phases of development, organization, planning and implementation of projects/initiatives/workflows/processes to enhance quality-driven outcomes.

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Department: Health Services, Outpatient Services

Reports to: VP, Utilization Management

Location: Tampa, FL (Henderson Rd)

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Essential Functions:
  • Provides direction and oversight to ensure effective management of inpatient care, discharge planning, and prior authorizations.
  • Optimizes processes and workflows to achieve successful quality outcomes and benefit maximization within the scope of responsibility.
  • Possesses the flexibility to act as a subject matter expert liaison for Clinical Services and/or a leader on cross-functional teams.
  • Serves as an instrumental partner in development of key performance indicators. Monitors and tracks key performance indicators to independently identify over/under utilization patterns and/or deviation from expected results.
  • Formulates strategic solutions to enhance quality outcomes.
  • Executes periodic competitor utilization management program comparison and analysis to ensure WellCare's utilization management program maintains competitive edge.
  • Develops processes and procedures to ensure department-wide compliance with contractual, regulatory (Federal/State) and accreditation entities.
  • Provides leadership and support to front-line staff, supervisors and managers.
  • Leads talent management activities to develop and cultivate future leaders.
  • Promotes and improves environment of Provider and Health Plan partnership.
  • Ensures monitoring and tracking tools are in place to adequately link and assess production and quality driven work products and outcomes to individual performers.
  • Serves as the subject matter expert for inpatient and prior authorization management for future expansion and growth efforts
  • Develops formal policies, procedures and workflows that effectively guide work activity.
  • Develops formal department-specific new employee orientation and training programs.
  • Chairing monthly UM meetings.
  • Performs other duties as assigned.

Candidate Education:

  • A Bachelor's Degree in Nursing (BSN), Health Administration, Nutrition or business related field or equivalent work experience is required
  • A Master's Degree in Business, Public Health or Healthcare administration is preferred

Candidate Experience:

  • 7 years of experience in acute clinical/surgical experience and/or behavioral health clinical setting is required
  • 3 years of management experience in a managed health care setting is required
  • Current experience in utilization management to include pre-authorization, utilization review, concurrent review, discharge planning, and/or skilled nursing facility reviews are required

Candidate Skills:

  • Intermediate Demonstrated problem solving skills
  • Intermediate Ability to work within tight timeframes and meet strict deadlines
  • Intermediate Ability to lead/manage others
  • Intermediate Demonstrated analytical skills
  • Intermediate Ability to work in a fast paced environment with changing priorities
  • Intermediate Demonstrated written communication skills
  • Intermediate Demonstrated interpersonal/verbal communication skills
  • Intermediate Ability to create, review and interpret treatment plans
  • Intermediate Ability to identify basic problems and procedural irregularities, collect data, establish facts, and draw valid conclusions
  • Intermediate Demonstrate effective critical thinking and decision making skills
  • Intermediate Ability to communicate on any level required to meet the demands of the position
  • Intermediate Ability to correctly write business letters and comprehensive reports

Licenses andCertifications:
A license in one of the following is required:

  • Licensed Registered Nurse (RN) is preferred
  • Utilization review/management certification, or equivalent professional certification is preferred

Technical Skills:

  • Required intermediate skill level with Microsoft Excel, Word, Outlook, PowerPoint and Visio
  • Required intermediate skill level Healthcare Management Systems (Generic)

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Last Updated On: 12/9/2015