PreAuthorization Unit Supervisor

Metropolitan Jewish Health System, Inc.; New York (NY); On-site; USD 90,000 - 120,000; Full time

Job summary

Metropolitan Jewish Health System, Inc. seeks a Registered Nurse supervisor to oversee MLTC/DSNP pre-authorization operations. The role involves ensuring regulatory timeframes, guiding complex cases, and coordinating interdepartmental communication.

Requirements include NY RN licensure, 1–3 years of management experience, and familiarity with utilization management, case management, and InterQual criteria.

Qualifications

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

Responsibilities

• Oversee day-to-day functioning of MLTC/DSNP pre-authorization functions.
• Review data to monitor regulatory requirements, timelines, and outcomes.
• Provide direction for complex cases and educate staff on new criteria trends.
• Serve as liaison for interdepartmental communication.

Skills

Management experience

Utilization management

Case management

Nursing practice

InterQual knowledge

Regulatory compliance

CCM preferred

Education

Bachelor of Science in Nursing (preferred)

Tools

InterQual

Job description

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 Registered 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.