Associate Manager, Clinical Quality – Prior Authorization

Job Description:

• Supervise the Prior Authorization quality review program, including policies, procedures, and compliance controls
• 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 provider and member 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

Benefits:

• Flexible hours and work flexibility
• Work-life balance
• Continuous learning and career development
• Flexible vacation policy
• 401(k) employer match
• Comprehensive health benefits
• Educational assistance
• Leadership and technical development academies
• Up to 20% travel