The Clinical Lead interfaces with Health Plan leadership team and ensure prospective review/prior authorization requests are completed in a timely manner to meet contractual requirements and all reviews are conducted using nationally recognized and evidence based standards. Participates in Quality Improvement Projects as directed; Performs audits of medical records as directed; and assists the internal and external departments in preparation for audits and other regulatory activities.
- Ensures prior authorization requests are completed accurately, thoroughly, and in a timely manner to meet contractual requirements and ensure all reviews are conducted using nationally recognized and evidence based standards.
- Ensure staff are trained and there is adequate coverage; complete IRR audits per policy; coach and mentor staff; work with Director on employee performance issues; complete employee evaluations. Ensure team meets budget and performance goals.
- Participates in Quality Improvement Projects as directed. Performs audits of case files and staff work. Reviews and/or drafts policies and procedures that support the operation.
- Prepares for audits and other regulatory activities. Completes reports and documentation required by compliance department.
- Leads the charge in focus and implementation of the organization's culture and strategic plan in a way that aligns to the mission, vision and values of the organization. Additional tasked assigned as appropriate.
- Bachelor's degree preferred
- Arizona licensed LPN, RN or PA required
- One (1) to two (2) years managed care experience preferred
- Two (2) to three (3) years managing others preferred
- Prospective review experience preferred; knowledge of utilization management principles
- Position must be located in Arizona.
- Strong analytic skills and the ability to translate data into useable information.
- Ability to generate creative solutions, identify the best course of action and rapidly resolve complex issues/problem
- Excellent verbal and written communication skills