Area Clinical Authorization Specialist Lead

Reports directly to the Area Vice President of Clinical Operations and is responsible for preauthorization and reauthorization for skilled and nonskilled services in collaboration with the clinical case management team and following up. This position ensures compliance with MGA policies State policies and procedures and policies of accrediting agencies as well as responsible for maintaining compliance with all reimbursement guidelines and maintaining patient confidentiality/HIPAA guidelines

Duties and Responsibilities

Lead and Supervisory Duties:

• Oversee Clinical Authorization Specialist Staff: Supervise participate and provide leadership to Registered Nurses ensuring adherence to clinical protocols role responsibilities and company policies.
• Performance Monitoring: Regularly evaluate the performance of the clinical authorization staff offering constructive feedback guidance and support. Address any performance issues promptly to ensure quality of service and work performance.

Clinical Authorization Duties:

• Oversight of Quality Assurance and Improvement monitoring in collaboration with the local clinical and operational leadership teams to ensure Quality Management Program standards are being met.
• Work with the Authorization Departments and Clinical Leadership on incoming referrals to gather documents to submit patient information to obtain preauthorization for all MGA services.
   Work through pended PARs and gather further documentation
   Follow the patient through from referral to approval or denial process and report back to the corresponding offices the updates
   Track all denials and work with the local teams on the next steps (including COB P2P etc).
• Oversight of the employees reviewing authorization tools for each location and review for missing information and corrections for:
   Complete and holistic plan of cares that match the skilled needs of the patient
   Diagnosis
   Authorization tools
   Doctor orders
   Nursing Assessment
   Any other pertinent paperwork needed for submission
• Oversight of track all service line renewal auths for submission and work with the clinical team operational team and clients to gather documentation to submit auth to KEPRO
   Track all renewal auths for submission and work with local teams to gather documentation to submit auth to KEPRO
   Keep tracing up to date in real time
• Enforces/ demonstrates compliance with State/ Federal regulations.
• Ensures effective communication to coordinate the creation of each authorization submission packet.
• Finalize completed authorization packets to submit to insurance for approval.
• Document all conversations and authorization transactions in the management system.
• Communicate effectively with staff and management.
• Appropriately perform all other duties assigned by Supervisor (or designee).
• Supports and executes the mission ethics and goals of the company effectively.
   Represent themselves in a positive and professional manner in the company and community.
   Adheres to dress code with a clean and neat professional appearance.
   Reports on time and as scheduled to complete work within designated time.
   Adhere to all company policies and procedures outlined in Employee Handbook Employee Agreement or communicated from executive team.

Qualifications :

• Current state license as a Registered Nurse BSN preferred.
• Minimum of two years of nursing experience in a Home Health or Acute setting preferred.
• Minimum of two years of experience in completing authorization tools and authorization submittals for skilled home care services.
• Demonstrate leadership capabilities with strong supervisory and interpersonal skills.
• Detail oriented flexible good organizational and time management skills.
• Knowledge of cost management for clinical services.
• Maintain strict confidentiality; adhering to all HIPAA guidelines and regulations

Additional Information :

As an MGA Area Clinical Authorization Specialist Lead you can expect

• Annual Salary of $72000 $82000
• Health Dental & Vision Coverage
• Health Savings Accounts (HSAavailable if enrolled in high deductible plan)
• Flexible Spending Accounts (FSA & LPFSA)
• Dependent Care Reimbursement Accounts (DCRA)
• Employee Assistance Program (EAPavailable if enrolled in Health plan)
• 401(k) retirement plan
• Paid Time Off (PTO)
• Company Paid Holidays
• 100% Company Paid Life Insurance (if enrolled in Health plan)
• Voluntary Life Insurance
• Short & LongTerm Disability
• Critical Illness/Accident Insurance
• Hospital Indemnity Insurance
• Identity Protection Plan
• Legal Care Plan

Remote Work :

No

Employment Type :

Fulltime