JOB SUMMARY

The Prior Authorization RN Supervisor provides clinical leadership and operational oversight for the Prior Authorization function within Medical Management. This role ensures the timely, accurate, and compliant review of authorization requests in accordance with CMS regulations, NCQA standards, applicable health plan requirements, and evidence-based clinical guidelines (e.g. Milliman Care Guidelines).

The RN Supervisor oversees Registered Nurses, LVNs, and Prior Authorization Coordinators, provides clinical decision support for complex cases; performs and delegates utilization review activities, ensures escalation to Medical Directors as appropriate; and partners with the UM Manager and health plans to support quality of care, regulatory compliance, and efficient authorization workflows.

MINIMUM & PREFERRED QUALIFICATIONS

Education/Training

Minimum: Graduate of an accredited Registered Nursing program.

Preferred: Bachelor’s degree in Nursing or related field. Formal training or experience in utilization management, prior authorization, or medical management.

Experience 

Minimum: 3+ years of clinical nursing experience. Prior experience in utilization review, prior authorization, or managed care.

Preferred: Supervisory or lead experience in a UM or Medical Management setting. Experience in multi-specialty or delegated health plan environments.

Any combination of educational and work experience that would be equivalent to the stated minimum requirements would qualify for consideration of this position.

Certification(s)

Current State Registered Nursing License

Preferred: CCM, CPUR, or similar UM certification

Skills, Knowledge & Abilities

· Strong clinical assessment and decision-making skills.

· Ability to interpret medical records, clinical guidelines, and regulatory requirements.

· Knowledge of ICD-10, CPT, and HCPCS coding.

· Excellent verbal and written communication skills.

· Demonstrated leadership, coaching, and conflict-resolution abilities.

· Proficiency with Microsoft Office (Word, Excel, Outlook, PowerPoint) and electronic UM systems.

· Strong organizational skills with the ability to prioritize and manage multiple deadlines.