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Fallon Health Authorization Coordinator in Worcester, Massachusetts


About Fallon Health :

Founded in 1977, Fallon Health is a nationally recognized, not-for-profit health care services organization. From traditional health insurance products available throughout Massachusetts for all populations, to innovative health care programs and services for independent seniors, Fallon Health supports the diverse and changing needs of all those it serves. Fallon Health has consistently ranked among the nation’s top health plans, and is the only health plan in Massachusetts to have been awarded “Excellent” Accreditation 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 Fallon Health (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 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.


  • Administrates 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 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 Department Managers and/or Director, 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. 



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


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). * *

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.

Location US-MA-Worcester

Posted Date 3 weeks ago (9/3/2021 12:04 PM)

Job ID 6497

# Positions 1

Category Utilization Management