Prior Cert RN Manager

Job Description

Job Description

Arizona Priority Care (AZPC) is an Integrated Provider Network focused on providing whole-person care to Senior and Medicaid populations, through advanced value-based models. Our provider network is comprised of more than 6,000 health care providers, including primary and specialty care physicians, hospitals and ancillary providers. We have operated in the Arizona market for more than 13 years, based in Chandler, Arizona, and are an affiliate of Heritage Provider Network. As a leading value-based provider organization, we are committed to improving the quality of care, providing excellent member and provider experiences all while reducing cost.

As the Pre Cert RN Manager, you will lead a high-performing team focused on ensuring timely, accurate, and compliant prior authorization processing across multiple plans and regulatory frameworks. You'll drive operational excellence, support a culture of continuous learning and exceptional service, and help facilitate care coordination that directly impacts member outcomes.

Working closely with clinical leadership, your team, and external stakeholders, you'll ensure that all requests are processed according to CMS, NCQA, and payer turnaround requirements, delivering value to both members and providers.

POSITION DUTIES & RESPONSIBILITES

• Lead and support the Prior Authorization Supervisor and nursing staff to ensure effective daily department operations.
• Also assist in supporting and providing general oversight of Prior Authorization Coordinators – who report directly to Prior Auth Supervisor.
• Serves as the escalation point for complex prior authorization requests or operational concerns.
• Oversee staffing, performance, workflow optimization, and workload distribution across clinical and non-clinical roles.
• Facilitate departmental huddles, 1:1 meetings, and team training in partnership with the PA leadership.

Compliance & Quality Assurance

• Monitor and manage turnaround time compliance for Routine/Standard and Urgent/Expedited PA requests according to CMS, NCQA, and contractual standards.
• Conduct monthly internal audits of staff performance and documentation accuracy; provide coaching and feedback to maintain quality standards (98%+ accuracy goal).
• Ensure timely and accurate submission of internal and external utilization management (UM) reports and audit data.

Process Improvement & Reporting

• Analyze trends in prior auth denials, delays, and workload bottlenecks; propose and implement corrective actions.
• Lead or support process documentation, including SOP reviews, workflow changes, and performance metric tracking.
• Coordinate semi-annual underutilization review and contribute to the development of the UM Work Plan for executive leadership.

Stakeholder Engagement

• Acts as a liaison between the PA Team, Medical Directors, office staff, and physicians to resolve PA-related issues and promote collaboration.
• Providing ongoing training and mentorship to new hires and existing staff, emphasizing customer service, regulatory compliance, and AZPC policies.
• Support the Director of Clinical Services Operations in preparation for audits by CMS, health plans, or NCQA.

EDUCATION, TRAINING AND EXPERIENCE

• Graduated from an accredited Registered Nurse (RN) Program.
• Current, unrestricted RN License in the State of Arizona.
• 5+ years of experience in Utilization Management with comprehensive knowledge of prior authorization processes.
• .3+ years of leadership or supervisory experience in a healthcare, managed care, or payer environment.
• Solid understanding of Medicare, Medicaid, and state/federal managed care regulations, including NCQA Utilization Management standards.
• Strong working knowledge of Medicare, state and federal managed care regulations, and NCQA guidelines.
• Proven ability to communicate clearly and professionally in both verbal and written formats – critical for coordinating across clinical teams, providers and payers.
• Demonstrated attention to detail and documentation accuracy, especially important for regulatory compliance and audit preparedness.
• Strong analytical and problem-solving skills to identify workflow gaps and implement effective process improvements.
• Ability to prioritize and manage competing tasks in a high-volume environment with minimal supervision.
• Proficient in Microsoft Office tools (Outlook, Word, Excel, PowerPoint) and experienced with electronic health record (EHR) and prior authorization systems.

*This role requires FT in-office presence for the first 60 days of employment. Hybrid schedule available after initial training period.*

Compensation range: The annual range for this position is: $96,000 – $100,000