Senior Prior Authorization Ops & Clinical Compliance Manager

Superior Dental Care, Inc.; Brooklyn, Northern (OH, KY); Hybrid; USD 110,000 - 150,000; Full time

Benefits offered by this job

On-site fitness centers

On-site cafeteria

Laptop provided

Gym membership reimbursement

Employee discounts

Job summary

Medical Mutual seeks an experienced leader to manage prior authorization operations and clinical compliance. The role oversees daily work, ensures regulatory alignment, and partners with UM, CM, IT, and external vendors to deliver high-quality, compliant decisions.

You will coach PA reviewers, monitor KPIs, and drive process improvements while coordinating with cross-functional teams to achieve cost and quality goals.

Qualifications

• Graduate of a registered nursing program; BSN preferred.
• 8+ years in Utilization Management, Prior Authorization, Clinical Review, or Clinical Compliance.
• 3+ years of leadership or supervisory experience.

Responsibilities

• Oversee daily PA operations and compliance monitoring.
• Coach and develop PA reviewers and staff.
• Prepare operational and compliance reports for leadership and regulators.
• Ensure compliant determinations using InterQual, MCG, CMP criteria and benefit guidelines.
• Manage escalations and complex cases; coordinate with vendors.

Skills

Utilization Management

Prior Authorization

Clinical Compliance

CMS regulations

InterQual

MCG

HIPAA

Analytics / KPIs

Education

BSN (Bachelor of Science in Nursing)

Ohio RN license

Tools

Excel

Microsoft Office

Prior authorization platforms

Job description

Medical Mutual seeks an experienced leader to manage prior authorization operations and clinical compliance. The role oversees daily work, ensures regulatory alignment, and partners with UM, CM, IT, and external vendors to deliver high-quality, compliant decisions.

You will coach PA reviewers, monitor KPIs, and drive process improvements while coordinating with cross-functional teams to achieve cost and quality goals.