Manager, Prior Authorization Operations Clinical Compliance

Medical Mutual employees must submit their applications through MySource.

This is a hybrid remote role based out of the Brooklyn, OH office, with employees expected to work onsite on designated inoffice days each week.

Founded in 1934, Medical Mutual is the oldest and one of the largest health insurance companies based in Ohio. We provide peace of mind to more than 1.2 million members through our high-quality health, life, disability, dental, vision and indemnity plans. We offer fully insured and self-funded group coverage, including stop loss, as well as Medicare Advantage, Medicare Supplement, and individual plans.

We provide fully insured and self-funded group coverage, including stop loss, as well as Medicare Advantage, Medicare Supplement, and individual plans.

Ensures timely, accurate, and clinically appropriate authorization determinations while maintaining full compliance with federal, state, accreditation, and internal regulatory requirements. Oversees daily PA operations, compliance monitoring, audit readiness, corrective action planning, and workflow alignment across Clinical Quality Health Services. Partners closely with UM, CM, Quality, IT, and external vendors to ensure high quality, efficient, and compliant clinical operations.

• Manages daily prior authorization and clinical compliance operations, including workload distribution, productivity, quality, and service performance.
• Provides coaching, mentoring, and competency development for PA reviewers and clinical compliance staff.
• Prepares operational and compliance reports for leadership, committees, and regulatory bodies.
• Oversees policy and workflow adherence, performance management, hiring, training, and evaluation of assigned staff.
• Ensures timely, accurate, and compliant determinations using Inter Qual, MCG, and CMP criteria and benefit guidelines.
• Manages escalations, complex cases, and high impact determinations.
• Partners with UM, CM, Quality, IT, Provider Relations, and external vendors to maintain compliant and efficient operations.
• Supports implementation of new systems, workflows, and process improvements that strengthen operational effectiveness and regulatory compliance.
• Monitors operational and compliance KPIs and report trends to leadership.
• Fosters a culture of accountability, transparency, and continuous improvement.
• Evaluates individual and team performance to ensure departmental and organizational goals related to utilization, cost, quality, and productivity are met.
• Performs other duties as assigned.

• Graduate of a registered nursing program approved by the Ohio State Nursing Board. Bachelor of Science in Nursing preferred.
• 8+ years of experience in Utilization Management, Prior Authorization, Clinical Review, or Clinical Compliance. 3+ years of leadership or supervisory experience.
• Strong knowledge of CMS regulations, state UM requirements, NCQA/URAC standards, and medical necessity criteria (Inter Qual, MCG).
• Experience with compliance audits, CAP development, and regulatory monitoring.

• Registered Nurse with current State of Ohio license required.

• Comprehensive knowledge of prior authorization operations, clinical review workflows, utilization management, and benefit interpretation.
• Comprehensive knowledge of Inter Qual, MCG, Corporate Medical Policies, clinical documentation, and medical necessity criteria.
• Strong knowledge of CMS, state UM requirements, NCQA/URAC standards, HIPAA, NQTLs, audits, and corrective action processes.
• Strong knowledge of claims processing, medical terminology, payment analysis, cost containment, ICD-10, CPT, and HCPCS coding.
• Knowledge of managed care, care…