About the Role:

We are looking for an experienced Manager or Senior Manager - Patient Access to lead the Prior Authorization and Electronic Benefits Verification (EVBV) function. The role will be responsible for overseeing day-to-day operations, managing a team of patient access professionals, ensuring timely and accurate authorization processing, and driving operational excellence.

The ideal candidate will have strong expertise in prior authorization, patient access, medical billing, and revenue cycle management, along with proven experience in team leadership and healthcare operations.

The role will play a critical part in minimizing authorization-related delays and denials, improving patient access, ensuring regulatory compliance, and supporting an efficient revenue cycle.

Key Responsibilities:

Leadership and Team Management:

- Lead, manage, mentor, and develop a team of Prior Authorization and Patient Access Specialists.

- Manage daily workflows, workload allocation, productivity, and service-level targets.

- Establish clear performance expectations and monitor individual and team performance.

- Conduct regular performance reviews, provide constructive feedback, and identify development opportunities.

- Foster a collaborative, accountable, and performance-driven team environment.

Prior Authorization and Operational Oversight:

- Oversee the end-to-end prior authorization process for medical services, procedures, medications, and other patient services.

- Ensure authorization requests are submitted accurately and within defined turnaround times.

- Develop and implement standardized workflows and SOPs to improve operational efficiency.

- Identify process gaps and implement corrective actions to improve turnaround times and approval rates.

- Monitor pending, approved, and denied authorizations and ensure timely follow-up.

EVBV and Patient Access Operations:

- Oversee electronic verification of patient insurance benefits and eligibility where applicable.

- Ensure accurate interpretation of coverage, benefits, payer requirements, and authorization criteria.

- Work closely with patient access, clinical, billing, and revenue cycle teams to resolve coverage-related issues.

- Identify potential barriers to patient access and implement processes to minimize delays in care.

Performance and Quality Management:

- Define, monitor, and analyze key operational KPIs including authorization approval rates, turnaround time, denial rates, pending authorization volumes, productivity, quality and accuracy, and service-level adherence.

- Analyze trends and prepare regular operational performance reports.

- Conduct quality audits of authorization requests to ensure accuracy and completeness.

- Develop action plans to address performance gaps and recurring issues.

Compliance and Regulatory Requirements:

- Ensure all patient access and prior authorization activities comply with applicable federal, state, payer-specific, and healthcare regulations.

- Maintain awareness of changes in payer policies, medical necessity requirements, coding guidelines, and authorization processes.

- Ensure appropriate handling and protection of patient information in accordance with HIPAA and applicable healthcare privacy standards.

- Maintain high standards of accuracy, documentation, and quality across the authorization process.

Cross-Functional Collaboration:

- Act as a key point of contact for clinical teams, physicians, providers, and internal stakeholders regarding prior authorization requirements.

- Collaborate with billing, coding, patient financial services, clinical operations, and revenue cycle teams to resolve complex cases.

- Coordinate with insurance companies and third-party payers regarding authorization requirements and escalations.

- Support the appeals process for denied authorizations and identify root causes behind recurring denials.

- Partner with leadership to identify opportunities for process improvement and revenue-cycle optimization.

Desired Candidate Profile:

- Bachelor's degree in Healthcare Administration, Life Sciences, Business Administration, or a related field.

- 10 - 15+ years of relevant experience in prior authorization, patient access, medical billing, healthcare operations, or revenue cycle management.

- Proven experience in a people-management or supervisory role, preferably managing prior authorization or patient access teams.

- Strong hands-on knowledge of prior authorization processes across multiple medical services and specialties.

- In-depth understanding of US healthcare insurance, payer policies, benefits, eligibility, and medical necessity requirements.

- Experience working with major health plans and third-party payers.

- Strong understanding of healthcare revenue cycle processes and denial management.

- Experience with EHR systems, prior authorization platforms, insurance verification tools, and Microsoft Office Suite.

- Working knowledge of HIPAA and healthcare compliance requirements.

- Strong analytical and problem-solving skills with the ability to interpret operational data and identify trends.

- Excellent leadership, communication, stakeholder-management, and interpersonal skills.

- Ability to manage multiple priorities in a fast-paced healthcare environment.

- Proven ability to handle escalations, resolve complex authorization issues, and drive process improvements.

Key Skills:

- Prior Authorization, Patient Access, EVBV, Eligibility and Benefits Verification, Revenue Cycle Management, Healthcare Operations, Denial Management, Insurance and Payer Policies, US Healthcare, Team Leadership, KPI and Performance Management, Quality Assurance, HIPAA Compliance, Process Improvement, EHR, Healthcare Technology, Stakeholder Management.