Supervisor of Prior Authorizations (RN or LVN)

Supervisor of Prior Authorizations (RN or LVN) Northridge, CA $100,000 - $125,000 / Year is the amount that CareNational reasonably expects to pay someone for this position. Pay depends on experience and licensure.Position Overview: As the Supervisor of Clinical Denials, you will be responsible for leading and overseeing the clinical denials management process, ensuring accurate and efficient resolution of denials and appeals related to medical necessity and clinical documentation. This critical role requires a strong clinical background, extensive knowledge of healthcare billing and reimbursement processes, and excellent leadership and communication skills. Responsibilities: Clinical Denials Management: Oversee the clinical denials management process, including but not limited to initial review, analysis, and investigation of clinical denials and appeals. Leadership and Team Management: Provide guidance, direction, and support to a team of denial management specialists, case managers, and nurses to ensure efficient and effective handling of clinical denials. Performance Monitoring: Develop and implement key performance indicators (KPIs) to monitor and evaluate the team's performance and the effectiveness of clinical denial management processes. Appeal Preparation: Collaborate with healthcare providers, physicians, and interdisciplinary teams to gather relevant medical records and evidence for appeals related to clinical denials. Policy Development: Assist in the development and implementation of policies and procedures related to clinical denial management, ensuring compliance with regulatory guidelines and standards. Training and Education: Conduct ongoing education and training programs for staff to enhance their understanding of clinical denials, appeal processes, and best practices for avoiding denials. Quality Improvement: Participate in quality improvement initiatives to identify trends, root causes, and opportunities for process enhancement to reduce future clinical denials. Stakeholder Communication: Serve as a liaison between the clinical denials team and other departments, including revenue cycle, billing, coding, and finance, to facilitate effective communication and collaboration. Regulatory Compliance: Stay updated with industry regulations, payer guidelines, and changes in healthcare policies related to clinical denials and ensure compliance within the organization. Data Analysis and Reporting: Analyze data related to clinical denials, appeals, and recovery rates to present reports to upper management and provide strategic recommendations for improvement. Qualifications: Active and unrestricted Nurse license (RN or LVN). Bachelor of Science degree, preferably in Nursing (BSN) degree; or Master of Science degree preferred. 5+ years of progressive leadership demonstrated in prior-authorization, appeals & grievances, health plan oversight, or health plan compliance related experience in a health plan, medical group, IPA, or management company. Minimum of 5 years of clinical nursing experience in a hospital or acute healthcare setting. Prior experience in clinical denials management and appeals coordination is highly desirable. Strong knowledge of healthcare billing, coding, and reimbursement processes. Excellent analytical and problem-solving skills with the ability to interpret complex medical information. Proficiency in data analysis and reporting using relevant tools and software. Exceptional communication and interpersonal skills to effectively interact with various stakeholders. Strong leadership abilities with a focus on team-building and staff development. Detail-oriented, organized, and able to manage multiple priorities effectively. Knowledge of healthcare regulations, including Medicare and Medicaid guidelines. Certified Professional in Healthcare Quality (CPHQ) certification is a plus. #LI-NATIONAL #LI-ONSITE

Created: 2026-03-10