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Fallon Health Service Coordinator - Utilization Management 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:

Under the direction of the Manager IUM Prior Authorization, communicates with contracted and non-contracted facilities/agencies/providers to collect pertinent prior authorization request data and disseminates information to the Authorization Coordinators. Additionally, supports the authorization process by receiving incoming faxed/mailed/emailed/etc. requests and initiates entry of service request shells into core system (QNXT) and TruCare. Responsible for incoming calls from the multiple ACD lines for the UM department addressing and/or referring customer (provider/member) calls/inquiries, provide direction regarding Plan policies, procedures and when applicable, benefit information. Work in conjunction with other FCHP departments to assist in processing authorization information in order to facilitate the member’s medical services or the providers’ claims. Interprets and triages information to ensure appropriate action is initiated to meet regulatory bodies’ standards and to maintain the quality and timeliness of the authorization process.


Authorization Functions

  • Accepts authorization service requests and notifications for FCHP members, screens for member eligibility, additional active insurance coverage and authorization history from the core system.

  • Initiates entry of request(s) into core system (QNXT/TruCare) and case management application (TruCare) as applicable.

  • Updates authorization information in QNXT as a result of determinations made by Authorization Coordinators, Nurse Reviewers and/or Nurse Care Specialists.

  • Handles an appropriately high volume of daily auth entries into the core system (QNXT). This volume target will be communicated to the staff on a regular basis by the Manager as business needs dictate.

  • Prepares completed authorization records for filing in accordance with company record retention policy.

  • Assists with departmental auto fax process including running error reports and missing Fax # report on a daily basis as assigned.

  • Generates notifications to members, facilities and agencies according to established protocol (auto-fax notification process and auto-generated letter process from the core system

  • Interfaces with other FCHP departments to obtain and verify information relevant to pre-authorization requests (e.g. contract information, benefits, etc.), including authorization details when requested for Appeals.

  • Distributes departmental facsimiles; checks Right Fax no less than hourly throughout the day; follows established process for determining to whom facsimiles are to be delivered; researches facsimiles inappropriately addressed by using the core system (QNXT) or by communicating with appropriate individuals for assistance; redirects/saves facsimiles as indicated to the staff and/or G drive.

  • Manage applicable queues in both the core system (QNXT UM and Call Tracking) and the case management application (TruCare).

  • Enters/extends/changes approved authorizations within established parameters.


  • Communicates with contracted and non-contracted facilities/agencies/providers to collect pertinent data regarding an episode of care and give applicable policy information and/or authorization numbers and status to facility/agency.

  • Communicates with inter/intra departmental personnel with regard to all aspects of the authorization process as requested.

  • Responsible to provide first response to inbound call center. Handles calls from providers and members with excellent customer service.

  • Assist FCHP providers, members and/or their recognized authorized representatives with questions and concerns regarding authorizations.

  • Manage the ACD hunt line and handle calls appropriately with a focus toward excellent customer service. In addition the Service Coordinator will attain the targets for a customer service call center as set by FCHP. These targets will be communicated to the staff by the Manager.

  • Educates PCP offices on new authorization procedures as needed as well as answer benefit/claims/referral questions in support of the Customer Service function.

  • Manage the Call Tracking module in the core system (QNXT) as required.


  • Strictly observes the FCHP policy regarding confidentiality of member and provider information.

  • Handle other duties as assigned based on the needs of the business.


Education : Associates Degree Preferred. Some advanced education highly preferred.


Experience :

  • Two+ years office experience, preferably in a managed healthcare environment, call center experience helpful; knowledge of medical terminology required; computer literacy and data entry experience required.

  • Excellent telephone, typing and computer skills

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

  • Excellent organizational skills

  • Excellent listening/oral communication skills

  • Mature judgment: knows when to seek guidance/direction and or when to refer problems to management

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

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

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 1 month ago (11/4/2021 11:11 AM)

Job ID 6539

# Positions 1

Category Customer Service