Manager, PA/UM

Alliant Health Group is a family of companies that provides professional services supporting the effective administration of healthcare programs and funding to support healthcare improvement initiatives. Alliant Health Solutions provides Federal and state government entities with the services, expertise and information systems necessary to increase the effectiveness, accessibility and value of health care.

Currently, Alliant Health Solutions, a "2025 Best Place to Work and Healthiest Employer", seeks a Manager, Prior Authorization/Utilization Management(PA/UM). The PA/UM Manager has the ongoing responsibility for managing the operations of a professional multi-disciplinary work team responsible for the medical review of pre-procedure and emergency care from various medical specialties such as inpatient and outpatient procedures/care, medications, Durable Medical Equipment (DME),, office visits, therapies, transportation, and long-term care treatment. Management activities of day-to-day operations include all aspects of personnel management, planning, scheduling, workload management, communication and evaluating.

In this role, the ideal candidate will:

• Provides oversight and monitoring that all aspects of PA/UM and related activities as outlined in the contract scope of work, meeting deliverables and service level agreements.
• Provides expertise and direction to review staff on complicated review cases and monitors activities to assess need for on-going education.
• Manages personnel matters for work teams including recruitment, hiring, orientation, planning and coordination of in-service education, evaluations, disciplinary action, implementation of performance improvement plans, and development of staffing plans as outlined in the scope of work in accordance with company policies.
• Maintains expertise in InterQual criteria, knowledge of contract requirements, Department of Community Health (DCH) and Alliant Health Solutions policies.
• Participates in quality improvement and peer review activities including Performance Appraisal Evaluations on new staff, annual team member evaluations, and telephone audits, develop and administer Inter-rater Competency Exams and Nurse Peer Quality Audits.
• Interacts with DCH Program Specialists, Legal Department or Claims Resolution areas with guidance from Medical Directors and or Deputy Director, Utilization Review Services to resolve clinical or policy issues.
• Participates in and oversees the Utilization Review Accreditation Commission (URAC) education of the PAUM team with the Clinical Supervisors, collaborates with other internal departments to ensure appropriate URAC standards are met, and works with Deputy Director to satisfy URAC midcycle reviews and reaccreditation requirements virtually and onsite.
• Coordinates with DCH all written and oral communications intended to inform and educate providers, their representatives, and other Medicaid staff.
• Serves as primary liaison with the fiscal agent to facilitate resolution of issues concerning PA/UM areas.
• Establishes policies and procedures related to medical review areas and reviews annually. Updates as needed.
• Collaborates with Clinical Systems Analyst to improve team(s) efficiencies and productivity of information systems.
• Collaborates with Department Director on new business opportunities and/or endeavors.

Other Job Functions:

• Work in close collaboration with other team members to support the development of new projects and the continuous improvement of the overall work of the team.
• Promote core values of teamwork, professionalism, effective communication skills and positive behaviors.
• Work in close collaboration with other team members to support the development of new projects and the continuous improvement of the overall work of the team.
• Maintain security and confidentiality of all information in accordance with HIPAA laws and regulations and company policies.
• Demonstrate compliance with company corporate and departmental policies as evidenced by attendance, punctuality, and appearance.
• Perform other duties as assigned

Knowledge, skills and abilities required for this role include:

• Knowledge, skill and ability to lead, including the ability to build team, collaborate with a team and work independently
• Knowledge of and commitment to process improvement methodologies and quality accreditations or credentials
• Knowledge skill and ability to organize, prioritize and plan multiple projects and activities and meet deadlines
• Knowledge skill and ability to communicate in verbal and written formats, including the ability to prepare and deliver presentations to small and large audiences
• Advance theoretical clinical knowledge base and problem-solving skills
• Knowledge of Microsoft Office Suite including Excel and Word; and Internet
• Skill and ability to manage change, and challenging customers and situations
• Ability to travel by car or plane to Company locations, customer meetings or other locations as needed

Education, experience and training required and preferred for the position are below:

Required:

* Bachelor's degree in nursing from an accredited college or university

* Registered Nurse with current Georgia nursing license

* Ten (10) years healthcare experience; five (5) years of clinical experience, and three (3) years utilization review experience

* Supervisory experience, including self-directed work teams

Preferred:

* Masters' Degree

* Previous utilization management, case management, quality assurance, and / or claims experience

* Three (3) years of management experience or demonstrated leadership in current staff position

Alliant offers work/life balance and great benefits including medical, dental life, disability, paid-time off, retirement with match and contribution, disability, employee assistance program, parental life, and more. If interested, click the apply icon above to apply. Alliant Health Group ("the Company) is an Equal Opportunity Employer and Drug Free Workplace. In compliance with the Americans' with Disability Act (ADA) and Amendments Act (ADAAA), all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender, gender identity, national origin, disability or veteran status. If you are an individual with a disability and require a reasonable accommodation to complete any part of the application process, please let us know. Likewise, if you are limited in the ability to access or use this online application process and need an alternative method for applying, we will determine an alternative method for you to apply. Please contact 678-527-3000.