About us:

Fallon Health is a company that cares. We prioritize our members-always-making sure they get the care they need and deserve. Founded in 1977 in Worcester, Massachusetts, Fallon Health delivers equitable, high-quality, coordinated care and is continually rated among the nation's top health plans for member experience, service, and clinical quality. We believe our individual differences, life experiences, knowledge, self-expression, and unique capabilities allow us to better serve our members. We embrace and encourage differences in age, race, ethnicity, gender identity and expression, physical and mental ability, sexual orientation, socio-economic status, and other characteristics that make people unique. Today, guided by our mission of improving health and inspiring hope, we strive to be the leading provider of government-sponsored health insurance programs-including Medicare, Medicaid, and PACE (Program of All-Inclusive Care for the Elderly)- in the region. Learn more at fallonhealth.org or follow us on Facebook, Twitter and LinkedIn.

Brief Summary of Purpose:

The FH authorization process is an essential function to FH's compliance with CMS regulations, NCQA standards, other applicable regulatory requirements, and customer expectations. The FH Authorization Coordinator serves to administer the FH prior authorization process as outlined in the Plan Member Handbook/Evidence of Coverage, departmental policies and procedures, and regulatory standards. The Authorization Coordinator serves as a liaison between FH members and/or provider offices and FH with their authorization management issues. Thorough research, documentation, and corrective action planning must be established for each respective case and adjudication completed in accordance with existing regulations, policies, and standards.

Job Responsibilities:

Administers FH authorization processes as outlined in Member Handbook/Evidence of Coverage for all products, and in compliance with applicable CMS and NCQA standards and other state or federal regulatory requirements. Strictly adheres to department turn-around time standards established in accordance with regulatory standards.
• Enters, researches, investigates, and documents all authorizations from receipt to notification into QNXT and/or TruCare for all product lines.
• Approves authorizations when the authorization meets the criteria listed in the appropriate Prior Authorization Protocol, authorizations not meeting protocol parameters are prepared for review, including direct contact with physician's offices and physicians to obtain records and other clinical information in support of the request; ensures that all pertinent information accompanies requests for further review.
• Notifies members and providers of any additional instructions necessary once authorization approval has been obtained from the reviewers; answers questions and provides direction and support.
• Works with Department Supervisors, Manager and/or Director, or Clinical Staff including the Medical Directors to resolve issues; formulates improvement measures and response to members; prepares written correspondence to members.
• Print and mail member notification letters at the FH corporate office located at 10 Chestnut Street, Worcester, MA several times per month or as needed, as designated through a rotational in-office calendar or at the direction of a supervisor or manager.
• Adheres to department standards for completion of authorization turn-around time and notification.
• Accepts authorizations for FH members, screens for member eligibility and enters information into the FH Core system.
• Answers authorization questions from members and providers, as needed.
• Answers telephone calls via ACD queue, as needed, within the Plan's standards for quality and service.
• Communicates both by telephone , as needed, with FH providers and staff to facilitate the Pre-Authorization Process.
• Supports claims functions through authorization adjustment guidelines to assist with adjudication of claims provided for missing information.
• Special projects/other duties as assigned by Management.

Education:

High School Diploma; College degree (B.S. or B.A.) or equivalent preferred

License/Certifications:

Medical Terminology or Medical Coding helpful

Experience:

• 1-3 years professional experience in related position, preferably in health care.
• Experience in a managed care or call center setting or physician's office; knowledge of managed care and/or utilization management strategies advisable
• Excellent writing skills with familiarity and comfort with medical terminology.
• Ability to work independently and make appropriate decisions within the realm of set business and benefit guidelines
• Excellent interpersonal communication and problem-solving skills.
• Excellent research and documentation skills.
• Excellent writing skills.
• Computer literate, particularly in Windows based applications (Word, Excel, PowerPoint, and Access).

Fallon Health provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.

#P02