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Fallon Health Letter Writer - Growing Health Care Org! 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.

Brief summary of purpose :

Performs all functions associated with completing tasks related to inpatient and prior authorization denial letters and special approval letters. This position serves as the subject matter expert on UM letters and works in conjunction with other FH departments including Communications, Customer Service, UM and CM in the maintenance of existing letters and rollout of new letters. Collaborates closely with the UM Clinical and Prior Auth staff to ensure appropriate and applicable language is captured for accuracy, timeliness of appropriate written notification requirements and overall letter integrity. Review and interpret FH and CMS Policies and Procedures to ensure appropriate language is utilized in the letters based on product enrollment. Maintain the quality and timeliness of the letter process and adherence to FH criteria and Medicare guidelines to ensure NQCA compliance.


  • Maintain a library of CMS, Vendor and Commercial letters which are regulatory based and subject to audit by regulatory agencies and NCQA

  • Complete all tasks related to the inpatient denial letters from the TruCare application including CMS letters outside of the application within the Turn Around Time (TAT). This also includes as hoc urgently needed letters by clinical staff.

  • Completion of all denial letters and special approval letters for Prior Auth requests

  • Perform spell check and grammar check for appropriate sentence structure to ensure letter accuracy

  • Critically review letters to ensure that denial reasons, which may include complex medical information, are composed accurately and in a member-friendly manner with attention to reading levels.

  • Maintain inventory of letters and ensure letters are current, appropriate and compliant.

  • Serve as SME on TruCare inpatient letter implementation team

  • Collaborate with internal stakeholders to ensure integrity of letters

  • Periodic review of all letter templates to ensure that letters reflect current regulations and remain accurate in face and tone



High School Diploma or equivalent. Some advanced education highly preferred .

License/Certifications :



  • 3 years, preferably in a managed healthcare environment

  • Strong knowledge of medical terminology and proficient in Microsoft Office

  • Self-starter (able to identify when specifically assigned functions have been completed and to request additional work)

  • Excellent organizational skills

  • Ability to work in a fast paced environment

  • High level of written communication skills

  • Self-starter (able to identify when specifically assigned functions have been completed and to request additional work)

  • Excellent organizational skills

  • Ability to work in fast paced environment

  • Excellent written communication skills

  • Ability to maintain high degree of confidential/privileged patient and proprietary business information

  • Familiarity with or ability to become familiar with governmental regulations and accrediting agency health plan requirements

  • Computer Skills (QNXT, CaseNet, Excel, Word)


Job ID 5656

# Positions 1

Category Administrative/Clerical