Senior Director, Prior Authorization & Utilization

Regal-Medical-Grou; California; On-site; USD 160,000 - 180,000; Full time

Benefits offered by this job

Medical, Pharmacy, and Dental for all

Vision insurance

FSA

Life Insurance

Employee Assistance Program

Behavioral health services

401(k) retirement savings plan

Paid time off

Vacation

Sick time

Paid holidays

Tuition reimbursement

License renewal CEU reimbursement

Job summary

Regal Medical Group in West Hills, California, seeks a Sr. Director, Prior Authorization Clinical to oversee the prior authorization team and compliance staff, ensuring timely, high-quality care within CMS and state regulations.

The role requires RN licensure, 5+ years in prior authorization or related health operations, strong leadership, and project management skills, with on-site work in California. Comprehensive benefits and competitive pay are offered.

Qualifications

• Graduate of an accredited Registered Nursing program with a current, active RN license.
• 5+ years of progressive experience in prior authorization or related healthcare operations within a medical group, IPA, or management company, including claims experience and staff supervision and performance management.
• Proven ability to develop high-performing teams, lead project development and implementation, monitor productivity, and manage competing priorities and deadlines.
• Knowledge of CMS, DMHC, DHS, and major California health plan requirements.

Responsibilities

• Promote medical management principles to ensure right care at the right time and setting.
• Collaborate with Medical Directors to develop, implement, and improve UM policies and procedures.
• Ensure compliance with health plan, state, and federal regulations, including DMHC, Medicaid, CMS Medicare Part C & D, and NCQA requirements.
• Supervise prior authorization nurses, professional claims review nurses, UM coordinators, and compliance staff.
• Serve as a liaison among clinical staff, Medical Directors, providers, and health plans to resolve authorization and care coordination issues.
• Oversee professional claims review nurses and coders to support medical necessity determinations.
• Prepare departmental work plans, periodic reports, and audit documentation.
• Coordinate Utilization Management Committee activities and meetings.

Skills

Prior authorization experience

Staff supervision

Project management

Regulatory knowledge

Analytical skills

Communication

Technical proficiency

CA driver’s license

On-site work

Education

Registered Nursing degree

Job description

Regal Medical Group in West Hills, California, seeks a Sr. Director, Prior Authorization Clinical to oversee the prior authorization team and compliance staff, ensuring timely, high-quality care within CMS and state regulations.

The role requires RN licensure, 5+ years in prior authorization or related health operations, strong leadership, and project management skills, with on-site work in California. Comprehensive benefits and competitive pay are offered.