Pre-Authorization Director

About the role

The Pre-Authorization Director leads the strategic planning and daily operations of the Preauthorization department, ensuring that all medical services, procedures, and pharmaceutical requests meet clinical guidelines, patient benefit packages, and regulatory requirements before care is delivered. This role drives cost‑containment initiatives while maintaining high‑performance standards and efficient workflow turnaround.

Key responsibilities

• Develop and execute comprehensive cost‑containment strategies to reduce out‑of‑network utilization and prevent unnecessary expenditures.
• Stay current with Medicare, Medicaid, and commercial payer policies, adapting workflows to maximize reimbursement and minimize financial leakage.
• Analyze utilization data, denial trends, and financial reports to identify waste and operational bottlenecks, creating actionable mitigation plans.
• Collaborate with Utilization Review, Contracting, Billing, Clinical Leaders, and Medical Groups to align preauthorization processes with corporate financial and clinical goals.
• Lead, mentor, and evaluate a multidisciplinary team of specialists, nurses, supervisors, and managers, fostering a culture of continuous improvement.
• Define, monitor, and enforce KPIs such as first‑pass authorization rates, turnaround times, denial and overturn rates, and individual productivity.
• Standardize and automate workflows using the latest EHR systems and AI‑driven authorization tools for process optimization.
• Ensure strict compliance with state/federal regulations, NCQA, URAC, HIPAA, and oversee internal audits for documentation accuracy.

Required profile

• Master’s degree in Health Services Administration or Nursing (Bachelor’s required, Master’s preferred).
• At least five years of progressive experience in prior authorization, utilization management, or revenue cycle management.
• Minimum three years in a leadership role overseeing large utilization‑management teams, preferably in a payer environment.
• Active clinical licensure (RN, LVN/LPN, or NP) highly preferred.

Required skills

• EHR systems
• AI-driven authorization tools