Senior Manager, Prior Authorization & Clinical Compliance

Medical Mutual; United States; Hybrid; USD 125,000 - 170,000; Full time

Benefits offered by this job

On-site gym

Employee bonus program

401(k) with company match

PTO & parental leave

Job summary

Medical Mutual in Brooklyn, OH, a hybrid-remote role, seeks a senior Utilization Management leader to oversee daily prior authorization and clinical compliance operations. The role partners with UM, CM, Quality, IT, and external vendors to ensure compliant and efficient clinical operations.

The successful candidate will coach PA reviewers, manage staff performance, and ensure determinations meet InterQual, MCG, and CMP criteria while aligning with organizational goals.

Qualifications

• Registered Nurse with Ohio license required.
• 8+ years in Utilization Management, Prior Authorization, Clinical Review, or Clinical Compliance.
• 3+ years of leadership or supervisory experience.
• Strong knowledge of CMS regulations and NCQA/URAC standards.

Responsibilities

• Manages daily prior authorization and clinical compliance operations.
• Provides coaching, mentoring, and competency development for PA reviewers.
• Prepares operational and compliance reports for leadership and regulatory bodies.
• Oversees policy and workflow adherence, performance management, hiring, training, and evaluation of staff.
• Ensures determinations using InterQual, MCG, CMP criteria and benefit guidelines.
• Manages escalations, complex cases, and high-impact determinations.
• Partners with departments to maintain compliant and efficient operations.
• Supports implementation of new systems and process improvements.
• Monitors KPIs and reports trends to leadership.
• Fosters accountability, transparency, and continuous improvement.
• Performs other duties as assigned.

Skills

Utilization Management

Prior Authorization

Clinical Compliance

Leadership

CMS Regulations

Regulatory Audits

Excel

Education

RN License Ohio

BSN preferred

Tools

InterQual

MCG

EMR/EHR

Job description

Medical Mutual in Brooklyn, OH, a hybrid-remote role, seeks a senior Utilization Management leader to oversee daily prior authorization and clinical compliance operations. The role partners with UM, CM, Quality, IT, and external vendors to ensure compliant and efficient clinical operations.

The successful candidate will coach PA reviewers, manage staff performance, and ensure determinations meet InterQual, MCG, and CMP criteria while aligning with organizational goals.