Manager, Preservice Review at Avalon Administrative Services LLC

, , United States -

Full Time

Start Date

Immediate

Expiry Date

18 Apr, 26

Salary

0.0

Posted On

18 Jan, 26

Experience

5 year(s) or above

Remote Job

Yes

Telecommute

Yes

Sponsor Visa

Skills

Nursing, Leadership, Communication, Data Analysis, Healthcare IT, Managed Care, Prior Authorization, Medical Necessity, Training, Performance Monitoring, Interpersonal Skills, Process Optimization, Clinical Review, Problem Solving, SOP Management, Team Management

Industry

Hospitals and Health Care

Description

About Avalon Healthcare Solutions: Avalon Healthcare Solutions is the world's first and only Lab Insights company, bringing together our proven Lab Benefit Management solutions, lab science expertise, digitized lab values, and proprietary analytics to help healthcare insurers proactively inform appropriate care, reduce costs, and improve clinical outcomes. Working with health plans nationwide, the company covers over 44+ million lives and delivers 10-20% proven outpatient lab benefit savings. Avalon is pioneering a new era of value-driven care with its Lab Insights Program that captures, digitizes, and analyzes lab results in real-time to provide actionable insights for earlier disease detection, ensuring appropriate treatment protocols and driving down overall costs. Avalon is a portfolio company of Francisco Partners, a global private equity firm that specializes in investments in technology and technology-enabled service companies. Avalon is a high growth company where every associate has an opportunity to make a difference. Avalon has years of expertise in managing lab benefits and now is leveraging digitized lab results to drive quality clinical outcomes and proven savings. When you look at how we bring this to life, we offer Lab Insights solutions that work together to arm you with critical lab-driven insights to accelerate your value-driven care success. This is the first-of-its-kind suite of solutions to help you achieve the Triple Aim of improving the patient experience of care, improving the health of populations, and reducing the per-member cost of healthcare. You will be part of a team that shapes a new market and business. Most importantly, you will help Avalon to achieve its mission and improve clinical outcomes and health care affordability for the people we serve. For more information about Avalon, please visit www.avalonhcs.com [http://www.avalonhcs.com/]. Avalon Healthcare Solutions, and its affiliates, is an equal opportunity employer. This position description is subject to change at any time. As determined by the company based upon business needs, an employee in this position may be required to perform duties and take responsibility for work other than as described in this document. About the Manager, Preservice Review Position: The Manager, Preservice Review manages the day-to-day operations of the preservice review process for prior authorizations while collaboratively partnering and clinically supporting Avalon’s medical director leadership within the clinical review space, to drive consistent, efficient, and compliant execution of prior authorizations in accordance with established client, regulatory, and industry standard service level agreements. This position is eligible for remote work, but quarterly travel will be required to Avalon's corporate office located in Tampa, Florida. Manager, Preservice Review - Essential Functions and Responsibilities: * Manage the preservice review process from intake to final determination, ensuring timely and accurate processing of prior authorizations in compliance with regulatory/SLA requirements. * Train new Nurse Reviewers and Intake Coordinators. Ensures training materials and related SOPs are current and accurate for business owned processes. * Manage scheduling of Intake Coordinators and Nursing staff. * Monitor and evaluate individual Intake and Nurse clinical team performance, balancing quality with productivity, to ensure adherence to quality, NCQA, SLA standards. * Responsible for analyzing performance (individual and by team) trends, inefficiencies, and opportunities making data driven recommendations for improvements/change. * Partner and collaborate with senior clinical leaders (MDs) in application of clinical criteria and medical necessity to determine medical necessity throughout the clinical review process. * Acts as primary contact for escalated calls and/or escalated issues or calls that require additional research and/or special handling. * Serve as subject matter expert on prior auth policies, procedures, and systems during internal and external audits. * Perform other duties as assigned such as managing PSR UAT for system upgrades, enhancements. Manager, Preservice Review - Minimum Qualifications: * Associate’s degree * Active Unrestricted Multi-State Nursing (RN Only) License * 5+ years’ experience in performing preservice review, +1-2 years direct or indirect people leadership * Ability to read and interpret documents. * Excellent communication skills, including good grammar, verbal and diction. * Ability to navigate and master proprietary software programs and proficient in MS Office with basic computer and keyboarding skills. * Knowledge of managed care processes, including prior authorization and medical necessity criteria. * Excellent leadership and interpersonal skills to manage direct and cross-functional teams and stakeholders. Manager, Preservice Review - Preferred Qualifications: * Bachelor’s degree preferred. * Proficiency in healthcare IT systems, data analysis, and process optimization. * Able to recognize and translate insights into actionable strategies (i.e., trends into process improvements). * Previous experience in a small, private equity backed company helpful.

Responsibilities

The Manager, Preservice Review oversees the preservice review process for prior authorizations, ensuring compliance with regulatory and service level agreements. This role involves training staff, monitoring performance, and collaborating with clinical leaders to determine medical necessity.