JOB SUMMARY:

The Program Manager, Prior Authorizations effectively leads a subset of the Prior Authorization functional area with specific emphasis on nationwide payors without retro authorization windows within billing, collection or accounts receivable management, maintaining a full understanding of the billing information system. Manages the activities of staff through daily supervision while overseeing designated functional area across revenue cycle including but not limited to billing and pre-certification. Assists with implementing strategic goals by deploying internal and external staff.

PRIMARY RESPONSIBILITIES:

• Track/monitor all cases requiring true prior authorization.

• Create/provide weekly updates to leadership on all pending/processed cases.

• Participate in submission, follow up, and performing necessary action on adverse decisions of prior authorization requests.

• Provide strong, timely financial and business analytics for decisions by organizational stakeholders

• Develop actionable roadmaps for improving workflows and processes.

• Performs in-depth reviews/audits to identify issues/trends and create remediation plan(s).

• Support management of projects to ensure successful and timely completion.

• Support management in monitoring and tracking adherence of SOPs, SLA , productivity and quality standards set by leadership

• Evaluate key performance indicators, provide ongoing reports, and recommend business plan updates.

• Performs a wide range of analytics functions in a fast-paced team environment using tools such as Excel, Power BI and other business intelligence tools.

• Analyzes payer and product prior authorization, denial, and reimbursement trends.

• Designs and executes improvement projects.

• Conducts complex data analysis and data interpretation.

• Meets established deadlines timely, accurately, and with a sense of urgency.

• Supervise team including monitoring production and quality to specified goals.

• Assists with feedback for hiring, discipline and performance evaluations.

• Oversees the process of providing coverage in a production environment.

• Provides department orientation for all direct reports and coordinates training per job description.

• Ensures that on-going training is provided for established employees, including the development & maintenance of standard operating procedures.

• Liaisons with internal departments to promote ongoing communication and ensure accuracy.

• Acts as an escalated level of response for concerns and complaints.

• Assists staff with enforcing policy.

• Works with cross functional teams to manage the entire process from insurance verification to final collection of prior authorization.

• Monitors and validates adherence to policies and procedures, auditing as necessary.

• Completes projects and reports in a timely fashion on a daily, weekly or monthly basis per the direction of management.

• Develops, monitors, coaches, and manages staff, ensuring the development of employees through orientation, training, establishing objectives, communication of rules and constructive discipline.

• Promotes a positive working environment through role modeling, team development, respect, and being fair and consistent.

QUALIFICATIONS:

• Bachelor’s degree or equivalent years of experience. 

• Minimum of 3 years of experience in supporting a high volume, fast growing billing office within the laboratory setting is preferred.

• Bi-lingual (fluent in Spanish) preferred.

• Minimum 5 years of experience with prior authorization submission and revenue cycle management software.

KNOWLEDGE, SKILLS, AND ABILITIES:

• Thorough knowledge of healthcare reimbursement (government and private payers) including coverage, coding and payment and understanding of insurance billing practices.

• Demonstrated ability to develop and analyze payments, diagnose issues, and present findings to management.

• Must be able to communicate effectively both orally and in writing. Strong interpersonal skills.

• Strong organizational skills; attention to detail.

• Ability to proficiently use a computer and standard office equipment.

• Working knowledge of Microsoft Office.

• Previous experience with Google Enterprise Suite – Gmail, Slides, Sheets, Docs, Drive.

• Knowledge of payer eligibility and benefits. Health care research and analysis skills sufficient to support payer research healthcare policy library and state management.

• Conflict resolution skills. Must be able to resolve employee issues effectively and efficiently.

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