Director, Prior Authorization Operations | RN Preferred | West Hills, California

Position Summary
The Director of Prior Authorization oversees non-clinical prior authorization staff, primarily coordinators, responsible for intake and review of pre-certification referrals. This role ensures quality, cost-effective utilization management and strict adherence to UM policies and procedures across affiliated medical groups. This is an ON-SITE,Full-time permanenet position located in West Hills, California.

Key Responsibilities

• Lead, coordinate, and manage prior authorization staff and daily operations
• Develop and maintain efficient workflows to meet compliance, timeliness, and customer service KPIs
• Support Medical Director program goals and organizational UM objectives
• Develop, refine, and implement utilization management policies and procedures aligned with industry standards and current literature
• Collaborate with medical leadership to interpret and administer applicable regulations, including CMS, DMHC, and HICE requirements
• Oversee quality assurance and continuous improvement initiatives related to processes, workflows, and patient-centered service delivery
• Compile and analyze operational data to prepare performance and compliance reports
• Represent the department in internal and external meetings and collaborate cross-functionally with clinical leadership and key stakeholders

Qualifications

• Management experience in utilization management or prior authorization operations
• Experience with staff supervision, program management, and issue resolution
• Strong knowledge of regulatory requirements including CMS, DMHC, and HICE UM standards
• RN preferred; ideal candidate will possess a clinical background with prior authorization or utilization management leadership experience
• Project management experience preferred