Supervisor, Prior Authorization and Utilization Management

Alliant Health Group is a family of companies that provides professional services supporting the effective administration of healthcare programs and funding to support healthcare improvement initiatives. Alliant Health Solutions provides Federal and state government entities with the services, expertise and information systems necessary to increase the effectiveness, accessibility and value of health care.

Currently, Alliant Health Solutions, a "2025 Best Place to Work and Healthiest Employer", seeks a Supervisor, Prior Authorization/Utilization Management (PAUM).

As a Supervisor in our PA/UM Department, the ideal candidate will play a crucial dual role, leading a team of clinical and non-clinical staff, while performing Prior Authorization and Precertification Reviews. Responsibilities include:

• Perform pre-procedure and emergency reviews on various medical specialties such as inpatient and outpatient procedures/care, medications, Durable Medical Equipment (DME), office visits, therapies, transportation, and long-term care treatment. Process these reviews accurately and within applicable time frames.
• Evaluate initial clinical information and approve cases that meet criteria. Document clearly the rationale for all review decisions using appropriate criteria or nursing judgment.
• Refer cases not meeting criteria and cannot be approved by nursing judgment to a Referral Nurse Coordinator for review by a Peer Review Consultant on cases a nurse cannot approve.
• Consult with the Manager, PA/UM, or Medical Directors on issues related to Peer Consultant review decisions or cases requiring physician clarification.
• Maintain confidentiality of review information and medical records in accordance with HIPAA compliance, and Alliant Health Group's/Alliant Health Solutions' Policy.
• Accomplishes staff results by communicating job expectations; monitoring and appraising job results; coaching, counseling employees; coordinating, and enforcing systems, policies, procedures, compliance and productivity standards.
• Participates in quality improvement and peer review activities including performance appraisal evaluations on new staff, annual performance evaluations, telephone audits, Inter-rater Competency Exams and Nurse Peer Quality Audits.
• Oversight of team assigned Prior Authorization (PA) Types to ensure that the Medical Management and Utilization Review Services (MMURS) contract expectations are met/exceeded.
• Creates and monitors team assignments to ensure accuracy and timeliness of medical reviews in accordance with established clinical criteria and both state and federal guidelines.
• Ensures each reviewer is familiar with a variety of review types and the corresponding Department of Community Health (DCH) policies manuals involved.
• Assist the review staff with decision-making, problem identification and resolution.
• Orients and trains new hires to their respective job responsibilities; and may educate staff on process changes, URAC, quality or other needs.
• Perform other duties as assigned
• Work in close collaboration with other team members to support the development of new projects and the continuous improvement of the overall work of the team.
• Promote core values of teamwork, professionalism, effective communication skills and positive behavior.
• Maintain security and confidentiality of all information in accordance with HIPAA laws and regulations and company policies.
• Demonstrate compliance with company corporate and departmental policies as evidenced by attendance, punctuality, and appearance.
• Perform other duties, tasks and responsibilities as assigned

Education, experience and training required and preferred for the position are below:

Required:

• Registered Nurse, with three to five years recent clinical experience
• Current Georgia nursing license
• Referral Coordinator, UM, Nurse Reviewer, and/or Prior Approval experience
• Management experience or demonstrated leadership in current staff position required

Preferred:

• Bachelor's degree in nursing
• Prior Team Lead, Preceptor or Supervisory experience

Alliant offers work/life balance and great benefits including medical, dental life, disability, paid-time off, retirement with match and contribution, disability, employee assistance program, parental life, and more. If interested, click the apply icon and apply.

Alliant Health Group ("the Company) is an Equal Opportunity Employer and Drug Free Workplace. In compliance with the Americans' with Disability Act (ADA) and Amendments Act (ADAAA), all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender, gender identity, national origin, disability or veteran status. If you are an individual with a disability and require a reasonable accommodation to complete any part of the application process, please let us know. Likewise, if you are limited in the ability to access or use this online application process and need an alternative method for applying, we will determine an alternative method for you to apply. Please contact 678-527-3000.