Senior PA Operations & Clinical Compliance Leader
Medical Mutual
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Benefits offered by this job
Job summary
Medical Mutual in Brooklyn, OH is seeking a senior leader to oversee daily prior authorization operations, ensure timely and compliant determinations, and align clinical workflows across Clinical Quality Health Services in partnership with UM, CM, Quality, IT, and external vendors.
This hybrid role requires onsite in Brooklyn on designated days, with a focus on coaching staff, monitoring KPIs, audits, and continuous improvement to deliver high-quality care and regulatory compliance for Ohio’s
Qualifications
- Graduate of a registered nursing program; BSN preferred.
- 8+ years in Utilization Management, Prior Authorization, or Clinical Compliance; 3+ years leadership.
- Strong knowledge of CMS regulations and NCQA/URAC standards.
- Experience with compliance audits and CAP development.
Responsibilities
- Oversee daily prior authorization operations and performance.
- Coach and develop PA reviewers and staff.
- Prepare operational and compliance reports for leadership.
- Ensure policy adherence and staff performance management.
- Monitor KPIs and drive improvement.
Skills
Education
Tools
Job description
Medical Mutual in Brooklyn, OH is seeking a senior leader to oversee daily prior authorization operations, ensure timely and compliant determinations, and align clinical workflows across Clinical Quality Health Services in partnership with UM, CM, Quality, IT, and external vendors.
This hybrid role requires onsite in Brooklyn on designated days, with a focus on coaching staff, monitoring KPIs, audits, and continuous improvement to deliver high-quality care and regulatory compliance for Ohio’s
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