RN, Pre-Service & Concurrent Review

Job Title:

Supervisor, Pre-Service & Concurrent Review (Utilization Management)

Job Description

The Supervisor of Utilization Management Pre-Service (Clinical) leads a clinical pre-service team focused on prior authorization and pre-service utilization review. This role oversees day-to-day operations, directs a team of nurses and coordinators, and ensures that pre-service utilization management activities meet regulatory, timeliness, and quality standards. The supervisor maintains expert knowledge of commercial and government payer requirements, NCQA standards, and clinical criteria, while driving process improvement initiatives and collaborating with internal departments and external providers to support patient-centered, compliant utilization management.

Responsibilities

+ Oversee day-to-day pre-service utilization management operations, ensuring work queues move efficiently and cases are processed in a timely manner.

+ Supervise and coach a team of approximately 20 nurses and clinical staff, monitoring productivity, identifying challenges, and providing guidance and support.

+ Provide direct leadership oversight for assigned clinical pre-service teams, including staff assignments and daily direction.

+ Supervise Utilization Management Nurses and Coordinators, including conducting timely performance evaluations, addressing performance issues, and identifying training needs.

+ Escalate operational and clinical issues appropriately and provide clear direction to staff on resolution and next steps.

+ Assist with processing remaining authorizations and pre-service reviews when needed to support team productivity and timeliness.

+ Maintain current and accurate knowledge of commercial and government payer requirements, CMS, DMHC, NCQA, DHCS regulations, and health plan guidelines related to utilization management.

+ Partner with the non-clinical pre-service team as needed to align and improve current workflows and processes.

+ Support the UM Pre-Service Director and Delegation Oversight team in developing and updating departmental manuals, procedures, and processing standards related to the authorization process.

+ Maintain authorization production standards and statistics, ensuring production meets timeliness goals established by regulatory agencies and health plans, and report performance to management on a daily basis.

+ Develop, implement, and monitor standardized protocols for clinical team activities to facilitate integrated, proactive case management.

+ Act as a liaison with external organizations, maintaining effective lines of communication and collaborating directly with physicians and community providers as needed.

+ Evaluate staff performance and determine the quality of their work efforts, ensuring adherence to clinical and operational standards.

+ Develop or assist in the development of prior authorization and claims policies, incorporating current literature and professionally recognized standards.

+ Develop or assist in the development and implementation of policies and plans for effective patient-centered utilization management with a focus on pre-service activities.

+ Design and implement ongoing programs to measure, assess, and improve the quality of processes, workflows, treatment, and services delivered to patients.

+ Ensure optimal quality of care and service is provided through robust utilization management practices and continuous quality improvement.

+ Participate in Quality Assurance Programs, intervene in crisis situations, and investigate unusual incidents related to utilization management operations.

+ Lead and participate in departmental and cross-functional meetings, and represent the department in discussions and initiatives as needed.

+ Provide management-level oversight, including staff leadership, program management, and effective issue resolution within the pre-service utilization management function.

+ Apply nursing processes, case management principles, and continuity of care concepts to utilization review decisions across the age continuum.

+ Apply appropriate business rules, medical guidelines, clinical criteria, and health plan benefits to authorization decision-making, documenting rationale and research clearly.

+ Collaborate with stakeholders to navigate network and benefit limitations, identify alternatives that meet patient needs, and support positive clinical and financial outcomes.

+ Utilize disease management strategies and clinical criteria tools to support accurate level-of-care determinations and appropriate utilization of services.

Essential Skills

+ Active Registered Nurse (RN) license required.

+ Must hold a California RN license, including when working remotely from another state.

+ Extensive expertise in pre-service utilization management, including pre-certification, prior authorizations, turnaround times, requirements, criteria hierarchy, and appeals.

+ Minimum of 3 years of recent clinical nursing experience.

+ Experience supervising staff and monitoring productivity and performance…