Director, Preauthorization & Healthcare Strategy

Triple-S; Guaynabo (PR); On-site; USD 85,000 - 120,000; Full time

Job summary

Triple-S is seeking an experienced leader to head the Preauthorization department, driving strategic planning and daily operations to ensure clinically necessary, compliant, and cost-efficient care for our Puerto Rico members.

You will design workflows, mentor a multidisciplinary team, and collaborate with UR, contracting, billing, and clinical leadership to optimize turnaround times and reimbursement while minimizing denials.

Qualifications

• Bachelor’s degree in Healthcare Administration, Nursing, or related field required; Master’s preferred.
• Active clinical licensure (RN, LVN/LPN, or NP) highly preferred.
• 5+ years in prior authorization, utilization management, or healthcare revenue cycle management.
• 3+ years in leadership or managerial role overseeing large teams.

Responsibilities

• Develop and execute cost containment strategies to minimize out-of-network utilization and denials.
• Align preauthorization workflows with Medicare/Medicaid and commercial payer policies.
• Analyze utilization data and denial trends to identify bottlenecks and mitigate risks.
• Collaborate with UR, Contracting, Billing, Clinical Leaders, and Medical Groups to align goals.
• Lead and mentor a multidisciplinary team of preauthorization staff and managers.
• Define and monitor KPIs: first-pass authorization, turnaround times, denial rates, productivity metrics.
• Oversee staffing models and workload distribution to handle fluctuating volumes.
• Standardize and automate workflows using EHRs and AI-powered tools.
• Ensure adherence to state/federal regulations, NCQA/URAC/HIPAA, and audit processes.
• Serve as escalation point for complex cases and expedited appeals.

Job description

Triple-S is seeking an experienced leader to head the Preauthorization department, driving strategic planning and daily operations to ensure clinically necessary, compliant, and cost-efficient care for our Puerto Rico members.

You will design workflows, mentor a multidisciplinary team, and collaborate with UR, contracting, billing, and clinical leadership to optimize turnaround times and reimbursement while minimizing denials.