Pre-Authorization Unit Lead – Managed Care & Compliance

MJHS; New York (NY); On-site; USD 90,000 - 120,000; Full time

Job summary

MJHS is seeking a Nursing Supervisor to lead MLTC/DSNP pre-authorization operations in New York. The role includes oversight of daily functions, regulatory compliance, and staff guidance to handle complex cases efficiently.

The ideal candidate will have a nursing degree, NY RN licensure, management experience, and familiarity with InterQual and managed care regulations. CCM is preferred, ensuring high-quality patient access and care management.

Qualifications

• Graduate of an accredited nursing program; baccalaureate degree preferred.
• Minimum 1–3 years' management experience.
• Previous managed care experience in utilization management and/or case management.
• Minimum 1 year nursing practice in clinical settings (hospital, nursing facility, home health).
• Licensed to practice as a Registered Nurse in New York with current registration.
• CCM preferred.
• Knowledge of InterQual preferred.
• Knowledge of Federal and State regulatory requirements for managed care.

Responsibilities

• Oversee day-to-day functioning of MLTC/DSNP pre-authorization functions.
• Review data to monitor regulatory requirements and communication.
• Provide direction for complex cases and educate staff on new criteria trends.
• Monitor pending cases and ensure timely decisions.
• Liaise with interdepartmental teams to maintain smooth operations.

Skills

Nursing leadership

Utilization management

Case management

InterQual knowledge

Education

Bachelor's degree in Nursing

Tools

InterQual

Job description

MJHS is seeking a Nursing Supervisor to lead MLTC/DSNP pre-authorization operations in New York. The role includes oversight of daily functions, regulatory compliance, and staff guidance to handle complex cases efficiently.

The ideal candidate will have a nursing degree, NY RN licensure, management experience, and familiarity with InterQual and managed care regulations. CCM is preferred, ensuring high-quality patient access and care management.