Supervisor Utilization Management (Prior Authorization)

Supervisor Utilization Management (Prior Authorization) CalOptima Join Us in this Amazing Opportunity The Team You'll Join We are a mission driven community-based organization that serves member health with excellence and dignity, respecting the value and needs of each person. If you are ready to advance your career while making a difference, we encourage you to review and apply today and help us build healthier communities for all. More About the Opportunity We are hoping you will join us as a Supervisor Utilization Management (Prior Authorization) and help shape the future of healthcare where you'll be an integral part of our UM - Prior Authorization team, helping to strive for excellence while we serve our member health with dignity, respecting the value and needs of each of our members through collaboration with our providers, community partners and local stakeholders. You will monitor and supervise the department operations to ensure service standards are met. You will make recommendations regarding assignments based on assessment of workload, serve as a resource to the Prior Authorization staff regarding CalOptima Health's policies and procedures and regulatory requirements governing authorization processing. Lastly, you will provide ongoing monitoring and development of staff. Together, we are building a stronger, more equitable health system. Your Contributions To the Team: 50% - Supervisory Functions Participates in a mission-driven culture of high-quality performance, with a member focus on customer service, consistency, dignity and accountability.Assists the team in carrying out department responsibilities and collaborates with others to support short- and long-term goals/priorities for the department.Assists the manager as needed to ensure departmental and agency goals are met.Identifies learning opportunities for staff and develops training materials (e.g., desktop procedures and/or Microsoft PowerPoint presentations) to provide terviews potential candidates and makes recommendations for second round interviews and/or hiring of a candidate.Creates staffing assignments based on authorization priority, workload, current staffing and review of timeliness reports.Trains, audits, supervises and coaches Prior Authorization staff.Reviews staff monthly productivity metrics and identifies and conducts performance feedback and/or counseling/corrective action meetings with the assistance of Human Resources as necessary.Reviews workflows, procedures and/or policies and recommends or implements changes as appropriate.Reviews denials and modifications of member notifications prior to mailing and collaborates with staff to implement updates as necessary.45% - Program Support Assists in the monitoring of appropriate benefit checks, application of guidelines to determine medical necessity, appropriate routing and timely completion of authorization requests.Assists with the collection, monitoring and analysis of prior authorization indicators and activities.Provides coverage and expertise for other teams within the Utilization Management department.Conducts prior authorization presentations to internal or external customers.Serves as a subject matter expert (SME) to departmental staff, internal departments and affiliated health networks regarding authorization rules and processes.5% - Other Completes other projects and duties as assigned.Do You Have What the Role Requires? Associate degree in Nursing (ADN) PLUS 3 years of clinical nursing experience required, preferably in a managed care environment; an equivalent combination of education and experience sufficient to successfully perform the essential duties of the position such as those listed above may also be qualifying.2 years of progressive leadership experience, including direct supervision of staff in managed care and/or utilization management required.1 year of utilization management/prior authorization review experience required.You'll Stand Out More If You Possess the Following: Bachelor of Science degree in Nursing (BSN).What the Regulatory Agencies Need You to Possess? Current and unrestricted California Board Licensed Vocational Nurse (LVN) or Registered Nurse (RN) license required.Your Knowledge & Abilities to Bring to this Role: Develop rapport and establish and maintain effective working relationships with CalOptima Health's leadership and staff and external contacts at all levels and with diverse backgrounds.Work independently and exercise sound municate clearly and concisely, both orally and in writing.Work a flexible schedule; available to participate in evening and weekend anize, be analytical, problem-solve and possess project management skills.Work in a fast-paced environment and in an efficient manner.Manage multiple projects and identify opportunities for internal and external collaboration.Motivate and lead multi-program teams and external committees/coalitions.Utilize computer and appropriate software (e.g., Microsoft Office: Word, Outlook, Excel, PowerPoint) and job specific applications/systems to produce correspondence, charts, spreadsheets and/or other information applicable to the position assignment.Your Physical Requirements (With or Without Accommodations): Ability to visually read information from computer screens, forms and other printed materials and information.Ability to speak (enunciate) clearly in conversation and general communication.Hearing ability for verbal communication/conversation/responses via telephone, telephone systems and face-to-face interactions.Manual dexterity for typing, writing, standing and reaching, flexibility, body movement for bending, crouching, walking, kneeling and prolonged sitting.Lifting and moving objects, patients and/or equipment 10 to 25 pounds.Ways We Are Here For You You'll enjoy competitive compensation for this role.Our current hiring range is: Pay Grade: 315 - $109,892 - $175,827 ($52.83 - $84.5322).The final salary offered will be based on education, job-related knowledge and experience, skills relevant to the role and internal equity among other factors.This position is approved for Partial Telework ( If the position is Telework, it is eligible in California only ).A comprehensive benefits package.CalPERS pension program and additional retirement packages.Additional benefits and perks including:A generous PTO program.

Created: 2025-11-06