Description

About Avalon Healthcare Solutions:Avalon Healthcare Solutions is the nation's leader in diagnostic intelligence, uniquely focused on transforming the role of diagnostic testing across the healthcare ecosystem. Our proprietary Diagnostic Insights Platform delivers evidence-based policies, curated lab networks, and real-time analytics that simplify complex diagnostics, accelerate innovation adoption, and optimize diagnostic investments.Supporting over 30 health plans and 100+ million members nationwide, Avalon partners with payers and providers to ensure diagnostic testing is performed appropriately, efficiently, and at the right time. Our flexible solutions span routine and genetic testing management, automated adherence, and end-to-end diagnostics support—driving measurable value, reduced waste, and improved clinical outcomes.With unmatched scientific rigor, deep clinical expertise, and a performance-based model, Avalon is redefining how diagnostics power personalized care and healthcare value.  You will be part of a team that shapes a new market and business. Most importantly, you will help Avalon to achieve its mission and improve clinical outcomes and health care affordability for the people we serve.Avalon Healthcare Solutions is an Equal Opportunity Employer - Vet/Disability.  For more information about Avalon, please visit www.avalonhcs.com.

About the Manager, Preservice Review Position:

The Manager, Preservice Review manages the day-to-day operations of the preservice review process for prior authorizations while collaboratively partnering and clinically supporting Avalon's medical director leadership within the clinical review space, to drive consistent, efficient, and compliant execution of prior authorizations in accordance with established client, regulatory, and industry standard service level agreements.

This position is eligible for remote work, but quarterly travel will be required to Avalon's corporate office located in Tampa, Florida.

Manager, Preservice Review - Essential Functions and Responsibilities:

Manage the preservice review process from intake to final determination, ensuring timely and accurate processing of prior authorizations in compliance with regulatory/SLA requirements.

Train new Nurse Reviewers and Intake Coordinators. Ensures training materials and related SOPs are current and accurate for business owned processes.

Manage scheduling of Intake Coordinators and Nursing staff.

Monitor and evaluate individual Intake and Nurse clinical team performance, balancing quality with productivity, to ensure adherence to quality, NCQA, SLA standards.

Responsible for analyzing performance (individual and by team) trends, inefficiencies, and opportunities making data driven recommendations for improvements/change.

Partner and collaborate with senior clinical leaders (MDs) in application of clinical criteria and medical necessity to determine medical necessity throughout the clinical review process.

Acts as primary contact for escalated calls and/or escalated issues or calls that require additional research and/or special handling.

Serve as subject matter expert on prior auth policies, procedures, and systems during internal and external audits.

Perform other duties as assigned such as managing PSR UAT for system upgrades, enhancements.

Manager, Preservice Review - Minimum Qualifications:

Associate's degree 

Active Unrestricted Multi-State Nursing (RN Only) License

5+ years' experience in performing preservice review, +1-2 years direct or indirect people leadership 

Ability to read and interpret documents. 

Excellent communication skills, including good grammar, verbal and diction.

Ability to navigate and master proprietary software programs and proficient in MS Office with basic computer and keyboarding skills.

Knowledge of managed care processes, including prior authorization and medical necessity criteria. 

Excellent leadership and interpersonal skills to manage direct and cross-functional teams and stakeholders. 

Manager, Preservice Review - Preferred Qualifications:

Bachelor's degree preferred.

Proficiency in healthcare IT systems, data analysis, and process optimization.

Able to recognize and translate insights into actionable strategies (i.e., trends into process improvements). 

Previous experience in a small, private equity backed company helpful.

PM18

PI282078775