Fallon Health Authorization Coordinator - Health Plan Ops in Worcester, Massachusetts
About Fallon Health
Founded in 1977, Fallon Health is a leading health care services organization that supports the diverse and changing needs of those we serve. In addition to offering innovative health insurance solutions and a variety of Medicaid and Medicare products, we excel in creating unique health care programs and services that provide coordinated, integrated care for seniors and individuals with complex health needs. Fallon has consistently ranked among the nation’s top health plans, and is accredited by the National Committee for Quality Assurance for its HMO, Medicare Advantage and Medicaid products. For more information, visit fallonhealth.org.
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 administrate the FH pre-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.
Transplant Coordinator duties (as assigned)
As a transplant authorization coordinator, the role must also sever as a liaison with the contracting department as well as a primary contact for Fallon’s re-insurance vendor. The Transplant Coordinator performs and tracks the FH authorization process as it relates to all services for transplants including pre-transplant evaluations, actual transplant services (admissions) and post-transplant follow-up services.
Administrates FH authorization processes as outlined in Member Handbook/Evidence of Coverage for all products, and in compliance with applicable 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 referral 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 Supervisor, Department Managers, or Medical Director to resolve issues; formulates improvement measures and response to members; prepares written correspondence to members.
Adheres to department standards for completion of referral TAT and notifications.
Accepts authorizations for FH members, screens for member eligibility and enters information into the FH Core system.
Answers claims/authorization questions from members and providers.
Answers telephone calls via ACD queue on daily basis within the Plan’s standards for quality and service.
Communicates both by telephone and on-site with FH providers and staff to facilitate the Pre-Authorization Process.
Supports claims functions through referral adjustment guidelines to assist with adjudication of claims provided for missing information.
Special projects/other duties as assigned by Management..
Transplant Coordinator Duties (as assigned):
Communicates with FH contracting department to obtain appropriate transplant network to be utilized.
Notifies FH re-insurance vendor when applicable.
Refers members to case management in the clinical application system and follows them collaboratively with the case manager if they are appropriately opened to CM.
Documents applicable transplant network being utilized in member’s record in QNXT.
Serves as primary contact into FH for transplant members.
Maintain tracking log of all transplant members for pre-transplant evaluations, transplant services and post-transplant follow-up services.
Education : High School Diploma; College degree (B.S. or B.A.) or equivalent preferred
Certification : Medical Terminology or Medical Coding helpful
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).
Job ID 5304
# Positions 1
Category Utilization Management