Provides oversight of Pre-Authorization unit to ensure all organization determinations are within regulatory compliance for time frames and notification parameters through ongoing monitoring of the unit’s activity.

Development and direct oversight of all MLTC/MAP organization determination/authorization processes to ensure timeliness and compliance with CMS/DOH regulations.

Collaborates in development of goals, objectives and performance measures and outcomes for the Coordinated Care Department.

Reviews/Revises all workflows and policies for the Pre-Authorization unit on at least annual basis to ensure compliance with DOH and CMS regulations. Communicates changes required for compliance within and outside of Coordinated Care Department, including Member Operations, Customer Service, Claims, Compliance, and Appeals and Grievances departments.

Ensures Interqual (IQ), interal policies and other criteria (NYS DOH, NCD, LCD) are applied consistently among staff through daily monitoring and review of the requests for services assigned to the unit. Educates staff on any changes to criteria/policy. Discusses with Director, the need for additional medical policy when gaps in coverage criteria are noted.

Conducts periodic focused medical records reviews for Pre-Authorization unit by using department specific audit tools and provides additional education as needed. Analyzes combined collected audit data and reports findings to Coordinated Care management. Works with Staff Educator on re-training efforts either on site or through Webinar sessions.