Director of Procedure
360X Staffing, Irvine, CA, United States
Position Summary:
The Director, Prior Authorization will be responsible for development of and maintenance of Prior Authorization and Denial Compliance Job Aids, Work Flows, procedures & related documents and ensuring alignment with HPN and regulatory Policies and guidance in compliance with DMHC, DHCS, CMS & NCQA requirements, as well as Health Plan contractual obligations.
Essential Duties and Responsibilities include the following: Develops, updates and maintains Prior Authorization Job Aids, procedures, program descriptions and related documents in compliance with DMHC, DHCS, CMS & NCQA requirements, as well as Health Plan contractual requirements, HPN Policies and direction from Compliance. Develops a process to keep up to date on regulatory and accreditation changes as well new and modified HPN policies and uses this information to proactively update trainings, job aids, and other helpful tools for Prior Authorization. Develops feedback mechanisms to ensure work being performed is delivering on needed results – i.e., meeting/exceeding compliance and service requirements. Develops, updates and maintains Prior Authorization compliance and procedural related training courses. Presents trainings in webinars or in-person as appropriate or needed. Reviews audit results (CQM, internal, HPN, health plans, regulatory, others) to review trends and collaboratively works with Prior Authorization management to develop the tools, trainings, job aids, communication tips, to support improved results as measured by audits and customer feedback. Develops, updates and maintains training materials to support Prior Authorization policies, procedures and job aids. Collaborates with PA leadership, Compliance, HPN, others to obtain consensus on job aids that are compliant with Policies and Procedures. Develops, updates and maintains job aids, workflows and training materials to improve the performance and consistency of Prior Authorization and develops an easily accessible staff resource center for PA. Identifies opportunities to improve quality, increase productivity and improve cycle time by reducing wasted time, errors, and rework resulting in business improvement.
Essential Duties and Responsibilities include the following: Develops, updates and maintains Prior Authorization Job Aids, procedures, program descriptions and related documents in compliance with DMHC, DHCS, CMS & NCQA requirements, as well as Health Plan contractual requirements, HPN Policies and direction from Compliance. Develops a process to keep up to date on regulatory and accreditation changes as well new and modified HPN policies and uses this information to proactively update trainings, job aids, and other helpful tools for Prior Authorization. Develops feedback mechanisms to ensure work being performed is delivering on needed results – i.e., meeting/exceeding compliance and service requirements. Develops, updates and maintains Prior Authorization compliance and procedural related training courses. Presents trainings in webinars or in-person as appropriate or needed. Reviews audit results (CQM, internal, HPN, health plans, regulatory, others) to review trends and collaboratively works with Prior Authorization management to develop the tools, trainings, job aids, communication tips, to support improved results as measured by audits and customer feedback. Develops, updates and maintains training materials to support Prior Authorization policies, procedures and job aids. Collaborates with PA leadership, Compliance, HPN, others to obtain consensus on job aids that are compliant with Policies and Procedures. Develops, updates and maintains job aids, workflows and training materials to improve the performance and consistency of Prior Authorization and develops an easily accessible staff resource center for PA. Identifies opportunities to improve quality, increase productivity and improve cycle time by reducing wasted time, errors, and rework resulting in business improvement.