Area Clinical Authorization Specialist Lead

Reports directly to the Area Vice President of Clinical Operations and is responsible for pre-authorization and re-authorization for skilled and non-skilled services in collaboration with the clinical case management team and following up. This position ensures compliance with MGA policies, State policies and procedures, and policies of accrediting agencies, as well as responsible for maintaining compliance with all reimbursement guidelines and maintaining patient confidentiality/HIPAA guidelines Duties and ResponsibilitiesLead and Supervisory Duties:Oversee Clinical Authorization Specialist Staff: Supervise, participate, and provide leadership to Registered Nurses, ensuring adherence to clinical protocols, role responsibilities, and company policies.Performance Monitoring: Regularly evaluate the performance of the clinical authorization staff, offering constructive feedback, guidance, and support. Address any performance issues promptly to ensure quality of service and work performance.Clinical Authorization Duties:Oversight of Quality Assurance and Improvement monitoring in collaboration with the local clinical and operational leadership teams to ensure Quality Management Program standards are being met.Work with the Authorization Departments and Clinical Leadership on incoming referrals to gather documents to submit patient information to obtain pre-authorization for all MGA services.

- Work through pended PARs and gather further documentation

- Follow the patient through from referral to approval or denial process and report back to the corresponding offices the updates

- Track all denials and work with the local teams on the next steps (including COB, P2P, etc).Oversight of the employees reviewing authorization tools for each location and review for missing information and corrections for:

- Complete and holistic plan of cares that match the skilled needs of the patient

- Diagnosis

- Authorization tools

- Doctor orders

- Nursing Assessment

- Any other pertinent paperwork needed for submissionOversight of track all service line renewal auths for submission and work with the clinical team, operational team, and clients to gather documentation to submit auth to KEPRO

- Track all renewal auths for submission and work with local teams to gather documentation to submit auth to KEPRO

- Keep tracing up to date in real timeEnforces/ demonstrates compliance with State/ Federal regulations.Ensures effective communication to coordinate the creation of each authorization submission packet.Finalize completed authorization packets to submit to insurance for approval.Document all conversations and authorization transactions in the management system.Communicate effectively with staff and management.Appropriately perform all other duties assigned by Supervisor (or designee).Supports and executes the mission, ethics, and goals of the company effectively.

- Represent themselves in a positive and professional manner in the company and community.

- Adheres to dress code with a clean and neat professional appearance.

- Reports on time and as scheduled to complete work within designated time.

- Adhere to all company policies and procedures outlined in Employee Handbook, Employee Agreement, or communicated from executive team.