Associate Manager, Clinical Quality – Prior Authorization

🕒 October 12

🇺🇸 United States – Remote

💵 $71.5k - $102.1k / year

⏰ Full Time

🟡 Mid-level

🏥 Clinical Operations

🦅 H1B Visa Sponsor

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Gainwell Technologies

WebsiteLinkedInAll Job Openings

10,000+ employees

💼 Consulting

📦 Logistics

⚕️ Healthcare Insurance

💰 Grant on 2023-06

Consulting • Logistics • Healthcare Insurance

Gainwell Technologies is the nation’s leading provider of digital and cloud-enabled solutions across the human services and public health ecosystem. With a mission-driven approach, Gainwell serves clients in all 50 U. S. states, focusing on improving health outcomes and delivering intuitive, human-centered experiences. Their comprehensive suite of solutions includes Medicaid Enterprise modernization, data analytics, provider services, and pharmacy solutions, all designed to advance the future of healthcare and enhance community well-being.

📋 Description

• Supervise the Prior Authorization quality review program, including policies, procedures, and controls supporting compliance with standards, regulations, accreditation requirements, and contracts • Develop and maintain quality assurance processes, audit methodologies, and performance benchmarks for medical and behavioral health Prior Authorization reviews • Supervise and mentor clinical quality auditors and reviewers through education, coaching, and performance feedback • Monitor and report quality, accuracy, timeliness, productivity, denial rationale, and interrater reliability metrics • Identify trends, root causes, and improvement opportunities in clinical criteria application, documentation, review consistency, and workflows • Analyze audit results, appeals, complaints, and regulatory findings to identify issues and recommend corrective actions • Prepare reports and dashboards for leadership on performance, audit outcomes, risks, and improvement initiatives • Ensure Prior Authorization reviews are completed accurately, consistently, and within required timeframes • Develop and deliver training based on audit findings, policy updates, and performance trends • Maintain knowledge of CMS, Medicaid, accreditation standards, clinical policies, and industry practices • Lead quality improvement initiatives that enhance accuracy, consistency, efficiency, and experience • Serve as a subject matter expert for new tools, automation, operational readiness, and escalated quality issues • Manage individual and team performance to meet or exceed performance standards • Perform other duties as assigned

🎯 Requirements

• Associate degree required; bachelor’s degree preferred • Current, unrestricted RN license required • Additional utilization management, case management, or healthcare quality certification preferred • Working knowledge of Prior Authorization, utilization management, medical necessity review, adverse determination processes, and applicable regulatory and accreditation requirements • Ability to apply evidence-based clinical criteria, health plan policies, benefit requirements, and clinical judgment consistently and accurately • Minimum 5 years of experience in Prior Authorization, utilization management, clinical review, or healthcare quality assurance • Minimum 2 years of leadership or quality assurance experience in a health plan, managed care, utilization management, or healthcare setting • Strong analytical, communication, coaching, and problem-solving skills • Experience using quality data to drive measurable improvement • Up to 20% travel

🏖️ Benefits

• Flexible hours and work flexibility • Work-life balance • Continuous learning and career development • Generous, flexible vacation policy • 401(k) employer match • Comprehensive health benefits • Educational assistance • Leadership and technical development academies