at Cook County Government in Chicago, Illinois, United States
Job Description
Job Posting:Jul 17, 2024, 3:01:16 PMClosing Date:Aug 1, 2024, 4:59:00 AMFull-timeShift Start Time:8:00A.M.Shift End Time:4:00P.M.
Collective Bargaining Unit:NonePosting Salary:COMPETITIVE
Organization:Health and Hospital Systems
LOCATION: STROGER HOSPITAL/INTEGRATED CARE MANAGEMENT DEPARTMENT
SHIFT: DAYS
JOB SUMMARY
The Prior Authorization Manager supervises, consults, and guides prior authorization staff responsible for responding to all prior authorization requests.The Prior Authorization Manager ensures all requests are complete to include inpatient, outpatient, procedures, and therapies in accordance with best practices, Cook County Health (CCH) Policies and Procedures and Health Plan standards.The Prior Authorization Manager ensures all documentation is obtained to support level of care, medical appropriateness, and authorization.
General Administrative Responsibilities
Collective Bargaining
Review applicable Collective Bargaining Agreements and consult with Labor Relations to generate management proposals
Participate in collective bargaining negotiations, caucus discussions and working meetings
Discipline
Document, recommend and effectuate discipline at all levels
Work closely with labor relations and/or labor counsel to effectuate and enforce applicable Collective Bargaining Agreements
Initiate, authorize and complete disciplinary action pursuant to CCH system rules, policies, procedures and provision of applicable collective bargaining agreements
Supervision
Direct and effectuate CCH management policies and practices
Access and proficiently navigate CCH records system to obtain and review information necessary to execute provisions of applicable collective bargaining agreements
Management
Contribute to the management of CCH staff and CCH' systemic development and success
Discuss and develop CCH system policies and procedures
Consistently use independent judgment to identify operational staffing issues and needs and perform the following functions as necessary; hire, transfer, suspend, layoff, recall, promote, discharge, assign, direct or discipline employees pursuant to applicable Collective Bargaining Agreements
Work with Labor Relations to discern past practice when necessary
Typical Duties
Develops and maintains a standardized prior authorization process to support departmental goals, to meet payer requirements, and support the achievement of CCH quality and cost objectives.
Manage the compilation, analysis and reporting of data/metrics in support of continuous improvement in processes and operations.
Monitors all Medicare and Medicaid Rules and Regulations, Medicare Conditions of Participation (CoPs), reimbursement methodologies, and Managed Care Organization (MCO) requirements and adjusts operations to meet changes.
Distributes and delegates assignments to staff.Establishes competency measures for each staff member.
Collects, monitors, evaluates, and communicates resource utilization and program metrics to support process and improvement and inform stakeholders.
Identifies variances in approval or denial patterns and collaborates with clinical departments to develop an action plan.
Maintains current knowledge of regulatory guidelines, a thorough understanding of a managed care contract's authorization requirements and Milliman Criteria.
Maintains a close working relationship with contracted Health Plans, updating/educating CCH staff and providers on authorization policies and procedures.
Creates scheduling and completion of all pre-authorization/ referrals in accordance with managed care payer policy as detailed in payer provider manual.
Attends and participates in meetings.Supports CCH committees and workgroups as assigned.
Performs related duties as necessary.
MINIMUM QUALIFICATIONS:
Bachelor's degree from an accredited college or university (Must provide copy of official college transcripts at time of interview). Is Required
A minimum of Three (3) years of experience with health plans and following insurance processes. Is Required
A minimum of Two (2) years payer or prior authorization experience. Is Required
A minimum of Two (2) years of supervisory or managerial experience. Is Required
Proficiency using Microsoft Office (Word, PowerPoint, Excel). Is Required
PREFERRED QUALIFICATIONS:
Bachelor's degree or higher in Health Care Administration, Organizational Development, Finance, or Accounting from accredited college or university? is Preferred
Experience with InterQual or Milliman guidelines? is Preferred
KNOWLEDGE, SKILLS, ABILITIES AND OTHER CHARACTERISTICS
In-depth knowledge of health care delivery systems-Illinois Medicaid, Medicare/Medicaid and services provided my managed care companies
Knowledge of InterQual or Milliman criteria set
Thorough knowledge and understanding of the Health Insurance Portability and... For full info follow application link.
COOK COUNTY HEALTH AND HOSPITALS SYSTEM IS AN EQUAL OPPORTUNITY EMPLOYER
