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Company: MedStar Medical Group
Location: Baltimore, MD
Career Level: Director
Industries: Not specified
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Description

General Summary of Position
The Director of Authorization and Pre-Certification for Surgical, Diagnostic, and Infusion Services is responsible for the strategic leadership and operational oversight of pre-service authorization and pre-certification for all scheduled procedures across hospital and ambulatory locations. This includes surgical cases, diagnostic imaging, infusion therapy, and other non-surgical outpatient services. The Director ensures timely and accurate completion of prior authorizations to prevent denials, reduce financial risk, and ensure seamless patient access. This role oversees cross-functional collaboration with scheduling, clinical, and financial clearance teams, and leads process improvements, automation initiatives, and compliance monitoring across all modalities requiring pre-approval.


Primary Duties and Responsibilities

  • Directs all pre-service authorization, pre-certification, and/or pre-visit clearance activities for surgical procedures, diagnostic imaging (e.g., MRI, CT, PET), oncology and infusion therapy, and other scheduled services.
  • Develops and implements standard operating procedures and strategic plans to support revenue cycle efficiency and timely patient access.
  • Evaluates and enhances use of automation tools and payer portals to reduce manual workload and improve authorization turnaround times.
  • Aligns departmental KPIs with system-wide goals for denial prevention, scheduling optimization, and revenue preservation.
  • Ensures authorizations are initiated and obtained for all scheduled surgical, diagnostic, and infusion services prior to the date of service, adhering to internal lead time benchmarks. Ensures escalations processes are followed to ensure financial pre-service clearance.
  • Coordinates closely with scheduling teams and clinical departments to track procedure schedules and payer authorization requirements.
  • Establishes escalation protocols for urgent or medically necessary cases lacking timely payer response. Oversees payer documentation requirements and ensures timely and complete submission of supporting clinical materials.
  • Tracks and trends denial reasons to identify patterns and recommend corrective actions to reduce future denials. Maintains accurate records of authorization denials, appeal submissions, and outcomes in electronic systems as required.
  • Ensures compliance with payer policies, hospital standards, and regulatory guidelines. Participates in performance improvement initiatives related to surgical pre-authorization and denial management.
  • Stays informed of payer authorization criteria, CMS regulations, and commercial plan variations, especially for high-cost services like chemotherapy and biologics.
  • Leads denial trend analysis and implement corrective action plans, including education, workflow redesign, and payer outreach.
  • Ensures proper documentation and audit-readiness of all authorization activities to maintain compliance with federal and state regulations.
  • Hires, trains, develops, and evaluates performance of managers, supervisors, and front-line staff across multiple service lines and locations.
  • Establishes clear productivity and quality benchmarks for surgical, diagnostic, infusion, and pre-visit authorization staff. Promotes a culture of accountability, teamwork, and continuous improvement.
  • Partners with perioperative services, imaging, oncology, infusion centers, registration, financial clearance, financial advocacy, counseling, and utilization review to ensure a coordinated pre-service process.
  • Participates in hospital committees and strategic initiatives related to access, revenue integrity, and care coordination. Serves as the subject matter expert and escalation point for complex or delayed authorizations.
  • Works with providers, scheduling teams, and pre-authorization staff to ensure that required documentation is secured before surgery or other procedure requests are submitted.
  • Identifies delays and inefficiencies in the authorization and pre-service clearance process and recommends workflow improvements.


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    Minimum Qualifications
    Education

    • Bachelor's degree Healthcare Administration, Business, Nursing required
    • Master's degree Healthcare Administration, Business, Nursing preferred
    • One year of relevant education may be substituted for one year of required work experience.

    Experience

    • 8-10 years Hospital revenue cycle or patient access operations required and
    • 5-7 years Managing prior authorization and pre-certification for surgical and non surgical services including diagnostic and infusion required and
    • 5-7 years Demonstrated success in managing high-volume pre-service operations in a multi-facility health system required or
    • 10+ years Bachelor's Degree requirement may be substituted with relevant experience, including at least 5 years in a leadership role within pre-service, financial clearance, or revenue cylce operations required or
    • 3-4 years Master's Degree may be offset by extensive leadership experience, performance improvement work in a hospital system. preferred
    • One year of relevant professional-level work experience may be substituted for one year of required education.

    Licenses and Certifications

    • CHAM - Certified Healthcare Access Manager within 1 Year preferred
    • Cert Revenue Cycle Rep - CRCR within 1 Year preferred
    • Epic Authorization Module Certification preferred
    • Lean Six Sigma or PMP preferred

    Knowledge, Skills, and Abilities

    • Deep knowledge of payer authorization requirements for surgical, imaging, and infusion services.
    • Strong leadership, communication, and change management skills.
    • Experience with Epic, MedConnect, IDX, or other EHR and payer portals, and authorization platforms.
    • Proficiency in analyzing trends, KPIs, and denial data to drive improvements.


    This position has a hiring range of $111,779 - $212,513

     


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