Prior Authorization Clinical Supervisor

It’s an exciting time to join the WellSense Health Plan, a growing regional health insurance company with a 25-year history of providing health insurance that works for our members, no matter their circumstances.

Job Summary

The Prior Authorization Clinical Supervisor is responsible for the daily supervision and operations of the Prior Authorization clinical team. Assigns work, ensures compliance with policies and procedures and is the first point of contact for complex issues to ensure cost effective prior authorization. In collaboration with the UM Clinical Trainer/QA, trains newly hired staff and ensures that ongoing training needs of incumbents are met. Under the direction of the Manager of Clinical UM, uses available data to prioritize prior authorization reviews and manage the queues. Works closely with, and may share specific business goals with other clinical and non-clinical supervisor within UM to ensure and support integrated UM processes.

Our Investment In You

• Full-time remote work
• Competitive salaries
• Excellent benefits
  
  

Key Functions/Responsibilities

• Monitors and evaluates the quality, timeliness and accuracy of prior authorization reviews
• Under the guidance of the UM Director and Managers Employs, employs recommended techniques to foster team work and staff development
• Uses subject matter expertise as well as knowledge of the interconnection between UM, benefits, claims, and regulatory requirements to respond to complex and/or escalated inquiries
• Utilizes critical thinking skills to identify process issues and problems, and recommend and/or implement solutions
• Under the direction of the UM Managers, develops and uses metrics and management reports to monitor staff productivity, efficiency, and quality
• May identify workflow and systems improvements to enhance UM’s ability to monitor, document and improve key department performance indicators
• Collaborates with the Inpatient Utilization Management team and the care management team(s)
• Participates in staff hiring, work allocation, training, performance management, including required documentation, and other supervisory functions under the guidance of the UM Managers
• Assists with and participates in the planning, development, and implementation of department specific and cross functional projects
• Identifies members who could benefit from care management under the Care Management Referral Screen and refers to the appropriate care manager
• In collaboration with the UM Clinical Trainer, is responsible for comprehensive orientation and ongoing training
• Employs the results of routine audits to monitor compliance with department standards and goals
• Provides high level of service and satisfaction to internal and external customers
• Responds to issues and concerns raised by staff and escalates to management as appropriate
• Participates in maintaining accurate, consistent, updated departmental policies, procedures and workflows and related training materials
• Other functions as required to support departmental activities
  
  

Qualifications

Education Required:

• Bachelor’s Degree in Nursing or nursing school degree with equivalent relevant work experience
• Master’s degree in Nursing, related clinical field or Health Care Administration is preferred
• CCM or Managed Care certification preferred
  
  

Experience Required

• One year of prior supervisory experience
• Three years related experience in an acute care or health insurance environment
• Two years’ experience with pre-authorization, utilization review/management, case management, care coordination, and/or discharge planning
  
  

Experience Preferred/Desirable

• Experience in home care and/or rehab nursing
• Experience with Medicaid/Medicare recipients and community services
• Experience with CCMS and/or Jiva, or other utilization management system
• Experience with InterQual or other nationally recognized medical necessity criteria
  
  

Required Licensure, Certification Or Conditions Of Employment

• Active unrestricted state licensure as a Nurse in the Commonwealth of Massachusetts
  
  

Competencies, Skills, And Attributes

• Demonstrated ability to lead a team
• Strong oral and written communication skills; ability to interact within all levels of the organization
• Demonstrated comfort with ambiguity and changes
• Demonstrated ability to create positive energy with individuals and groups
• Demonstrated ability to take action in solving problems while exhibiting sound judgement
• Strong organizational and time management skills
• Ability to work in a fast paced environment and multi-task
• A strong working knowledge of Microsoft Office applications
• Demonstrated ability to successfully plan, organize and manage projects
• Detail oriented, excellent proof reading and editing skills
• Strong analytical and problem solving skills
• Knowledge of analytics, metrics, and the ability to interpret data
• Knowledge of process improvement techniques
  
  

About WellSense

WellSense Health Plan is a nonprofit health insurance company serving more than 740,000 members across Massachusetts and New Hampshire through Medicare, Individual and Family, and Medicaid plans. Founded in 1997, WellSense provides high-quality health plans and services that work for our members, no matter their circumstances. WellSense is committed to the diversity and inclusion of staff and their members.

Qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, disability or protected veteran status. WellSense participates in the E-Verify program to electronically verify the employment eligibility of newly hired employees

Required Skills

Required Experience