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Fallon Health Letter Writer - Growing Insurance Co. in Worcester, Massachusetts

Overview

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 www.fallonhealth.org .

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, MassHealth, 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, MassHealth, and CMS guidelines to ensure NQCA and regulatory compliance.

Responsibilities

  • Utilizing knowledge from processing inpatient and/or prior authorization requests, complete all tasks required to produce, issue, and retain a timely and accurate written notification to the member and provider while adhering to regulatory and contractual requirements for content, structure, reading level, etc.

  • Written notifications include approval and denial letters for Acute Inpatient, Post-Acute, Elective Inpatient, and Outpatient

  • 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

  • Collaborate with internal stakeholders to ensure integrity of letters

  • Maintain letter inventory, and ensure letters are current, appropriate, and compliant with CMS, MassHealth, DOI regulations and contracts

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

  • Coordinate the approval of any new letter, revisions or annual updates with the Communications department

  • Serve as a SME for the Department for letter maintenance, and projects implementations

  • Participate as a SME for the Department in both internal and external audits’ file review

Qualifications

Education:

Bachelor’s Degree or equivalent experience

License/Certifications :

N/A

Experience:

  • 3 years’ experience, preferably in a managed healthcare environment, with prior authorization and utilization management processes and procedures

  • Ability to review and interpret regulatory-governed documents and medical terminology, and condense said language into a member-friendly letter

  • Ability to maintain and manage document inventory across multiple products

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

  • Ability to work in fast paced environment

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

  • Excellent organizational skills

  • Excellent written communication skills

  • Strong computer skills (QNXT, TruCare, Microsoft Office Word)

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

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.

PM16

Location US-MA-Worcester

Posted Date 1 month ago (3/4/2021 3:47 PM)

Job ID 6253

# Positions 1

Category Administrative/Clerical

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