Prior Authorization Associate Director

Prior Authorization Associate Director

Chandler, AZ

Schedule: Mon-Fri 8-5pm

Salary: $100,000 - 110,000 (dependent on experience and licensure)

Full time, direct hire

Job Details:

Department Leadership & Operations

• Provide department-wide accountability through the PA Supervisor and designated clinical leads, ensuring coordinated clinical and non-clinical Prior Authorization operations.
• Translate the Director's strategic direction into department priorities, performance expectations, governance standards, and measurable outcomes.
• Establish workforce strategy, capacity models, productivity standards, and resource recommendations;
  hold frontline leaders accountable for scheduling, workload distribution, attendance, and productivity.
• Resolve systemic, high-risk, or cross-functional issues that cannot be resolved at the Supervisor level;
  elevate clinical, regulatory, or organizational risks to the Director as appropriate.
• Lead department leadership meetings and mentor the PA Supervisor and clinical leads;
  set expectations for huddles, 1:1s, onboarding, coaching, and training carried out by frontline leadership.
• Evaluate and develop direct reports, strengthen leadership capability, and support succession planning;
  ensure frontline performance management is completed consistently by the PA Supervisor.

Compliance, Quality & Audit Readiness

• Ensure Medicare Advantage preservice operations comply with CMS, NCQA, contracted health plan, and applicable state and federal requirements.
• Own aggregate turnaround-time, notification, documentation, and compliance performance;
  review trend reporting and hold the PA Supervisor and clinical leads accountable for timely operational correction.
• Establish the department's quality-audit framework, sampling expectations, and performance targets;
  validate trends and oversee corrective action while routine staff audits and coaching are completed by the PA Supervisor.
• Maintain continuous audit readiness and lead preparation of PA documentation, reports, and supporting evidence for CMS, NCQA, health plan, and internal audits in partnership with the Director.
• Identify compliance gaps, complete root-cause analysis, develop, implement, and monitor corrective action plans through sustained resolution.

Process Improvement, Reporting & Programs

• Evaluate aggregate authorization volumes, denials, pends, delays, productivity, quality results, and workload trends to identify enterprise risks, capacity needs, and improvement priorities.
• Ensure timely, complete, and accurate internal and external UM reports, audit submissions, dashboards, and management updates, including barriers and planned intervention.
• Own governance and approval of standard operating procedures, workflows, job aids, and performance controls;
  delegate detailed maintenance, training, and frontline implementation to the PA Supervisor.
• Coordinate semiannual underutilization review activities and contribute to the UM Program, UM Work Plan, annual evaluations, and committee reporting.
• Lead delegated PA programs, vendor initiatives, system enhancements, and operational projects, including transition-of-care and continuity-of-care activities related to contract or capitation changes.

Stakeholder, Provider & Committee Engagement

• Serve as the senior escalation liaison with Medical Directors, health plans, providers, internal departments, vendors, and other partners for systemic, high-risk, or unresolved PA matters.
• Participate in UM and Quality Improvement Committees, Joint Operating Committees, provider and health plan meetings as assigned;
  prepare accurate supporting materials and follow-up actions.
• Lead resolution of escalated or systemic member and provider service issues, using trend findings to direct sustainable department improvements.
• Maintain working knowledge of contracted products and benefit structures relevant to PA operations, with particular expertise in Medicare Advantage.
• Represent the department professionally and communicate operational risks, performance, and recommendations clearly to leadership and stakeholders.

Job Requirements:

• Five or more years of progressively responsible Utilization Management experience, including comprehensive knowledge of Medicare Advantage prior authorization and preservice operations.
• Three or more years of management or supervisory experience in healthcare, managed care, delegated entity, or payer environment.
• Bachelor's degree in nursing, healthcare administration, business, or a related field preferred;
  equivalent relevant experience may be considered.
• Graduation from an accredited Registered Nurse program and a current, unrestricted Arizona RN license preferred but not required.
• Strong knowledge of CMS Medicare Advantage requirements, NCQA Utilization Management standards, managed care regulations, health plan requirements, and audit expectations.
• Demonstrated ability to lead clinical and non-clinical teams, manage competing priorities, and maintain performance in a high-volume environment. - Strong analytical, written, verbal, interpersonal, problem-solving, and change-management skills.
• Proficiency with Microsoft Office applications and experience with electronic health record, utilization management, prior authorization, and reporting systems.