Pre-Authorizations Director

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

At Triple-S, we are committed to providing meaningful job experiences for Valuable People (Gente Valiosa). We strive for excellence in everything we do, from the way we work together to the way we serve our customers.

When you join Triple-S, you will be key to our efforts on delivering high-quality and affordable healthcare as well as contribute to our purpose to enable healthier lives. We serve more than 1 million consumers in Puerto Rico through our Medicare Advantage, Medicaid, Commercial, Life and Property & Casualty Businesses.

Job Summary

Responsible for leading, strategic planning, and overseeing the daily operations of the Preauthorization department. This pivotal role ensures that all medical services, procedures and pharmaceutical requests meet clinical necessities aligned with clinical guidelines, patient plan benefit package and other regulatory or contract requirements before care is delivered. Responsible for designing and implementing robust cost containment strategies to minimize financial risk and denials, while simultaneously driving high-performance standards across your team to optimize workflow efficiency and turnaround times.

Essential Functions

• Develop and execute cost containment strategies. Formulate and implement comprehensive strategies to minimize out-of-network utilization, reduce unnecessary medical expenditures, and prevent costly authorization denials.
• Payer & Policy Alignment. Stay ahead of shifting healthcare regulations, Medicare/Medicaid guidelines, and commercial payer policies to adapt preauthorization workflows, ensuring maximum reimbursement and minimal financial leakage.
• Analyze high-level utilization data, denial trends, and financial reports to identify areas of waste or operational bottlenecks, creating actionable plans to mitigate risks.
• Partner closely with Utilization Review (UR), Contracting, Billing, Clinical Leaders, Medical Groups, and other cross-functional teams to align preauthorization processes with broader corporate financial and clinical goals.
• Lead, motivate, and mentor a multidisciplinary team of preauthorization specialists, nurses, supervisors and managers.
• Define, monitor, and enforce clear Key Performance Indicators (KPIs) for the team, including first-pass authorization rates, turnaround times (TAT), denial rates, overturned rates, volume per categories and LOBs and individual productivity metrics.
• Conduct regular performance evaluations, construct targeted Performance Improvement Plans (PIPs) when necessary, and foster a culture of continuous learning and accountability. Analyze workflows opportunities and establish action plans for improvements.
• Oversee staffing models and workload distribution to ensure the department is appropriately staffed to handle fluctuating volumes without sacrificing quality or speed.
• Standardize and automate preauthorization workflows leveraging the latest healthcare technology, EHR systems, and AI-driven authorization tools for process optimizations.
• Ensure all preauthorization activities strictly adhere to state/federal regulations, NCQA (MOC), URAC, HIPAA and other Regulatory Organizations standards. Oversee internal auditing processes to guarantee documentation accuracy.
• Serve as the ultimate point of escalation for complex clinical cases, high-dollar peer-to-peer reviews, and expedited appeal processes.

EDUCATION

• Master's Degree in Health Services Administration or Nursing
• Bachelor's Degree in Health Services Administration or Nursing

Experience

Bachelor’s Degree in Healthcare Administration, Nursing, or a related field is required. (Master’s Degree/MHA preferred). At least five (5) years of progressive experience in prior authorization, utilization management, or healthcare revenue cycle management. At least three (3) years in a dedicated leadership or managerial role, overseeing large teams in a utilization management system, preferable at payer environment.

Active Clinical Licensure (RN, LVN/LPN, or NP) is highly preferred.

LICENSES AND CERTIFICATIONS

COMPETENCIES

• Customer Delight
• Data Driven Insights
• Develops Talent
• Financial & Business Acumen
• One Company Mindset
• Practical Knowledge in Tech

It is company policy to seek for the qualified applicants for positions throughout the company without distinction of race, color, national origin, religion, sex, gender identity, real or perceived sexual orientation, civil status, social condition, political ideologies, age, physical or mental disability, veteran status or any other characteristic protected by law. Drug-free company.

Equality Employment Opportunity/Affirmative Action for People with Disabilities/Veterans. Employer with E-Verify to verify the eligibility of employment of all the new employees.

We encourage Veterans and Disabled to Apply.