Pre-Authorization Unit Supervisor

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

Come lead with us at New York, NY

The challenges of affordable healthcare continue to create new opportunities. Elderplan and HomeFirst, our Medicare and Medicaid managed care health plans, are outstanding examples of how we are expanding services in response to our patients' and members' needs. These high-quality healthcare plans are designed to help keep people independent and living life on their own terms.

The supervisor in this position is responsible for the oversight of the overall day to day functioning of the MLTC/DSNP pre-authorization functions. The supervisor’s daily oversight includes reviewing data to monitor regulatory requirements (standard/expedited time frames, org determination outcomes and communication, inter-rater reliability), provides direction for complex cases, monitors pending cases, reviews and educates staff on new criteria trends (including InterQual, local carrier policy, national coverage determinations), and acts as a liaison with interdepartmental communication.

• Graduate of an accredited nursing program: baccalaureate degree preferred.
• Minimum one to three years' previous management experience preferred.
• Previous managed care experience in the areas of utilization management and/or case management preferred.
• Minimum one year nursing practice in clinical settings, i.e. hospital, nursing facility or home health.
• Licensed to practice as a Registursed Nurse in the state of New York with current registration.
• CCM preferred
• Knowledge of InterQual preferred.
• Knowledge of Federal and State regulatory requirements for managed care.