Prior Authorization Team Lead Coordinator

About us:

Fallon Health is a company that cares. We prioritize our members-always-making sure they get the care they need and deserve. Founded in 1977 in Worcester, Massachusetts, Fallon Health delivers equitable, high-quality, coordinated care and is continually rated among the nation's top health plans for member experience, service, and clinical quality. We believe our individual differences, life experiences, knowledge, self-expression, and unique capabilities allow us to better serve our members. We embrace and encourage differences in age, race, ethnicity, gender identity and expression, physical and mental ability, sexual orientation, socio-economic status, and other characteristics that make people unique. Today, guided by our mission of improving health and inspiring hope, we strive to be the leading provider of government-sponsored health insurance programs-including Medicare, Medicaid, and PACE (Program of All-Inclusive Care for the Elderly)- in the region. Learn more at fallonhealth.org or follow us on Facebook, Twitter and LinkedIn.

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 administer 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.

Primary Job Responsibilities:

Follows the Case Management Standards of Practice, Ethical standards, department policies and procedures, and compliance regulations
• Obtain clinical, functional and psychosocial information from the medical records on site, through remote electronic access, telephonically or by fax, in a collaborative effort with other health care professionals, member and/or family
• Refers cases to medical review according to policy and procedure
• Documents clinical, functional, psychosocial information in the Core System as well as communications regarding the members' care
• Keeps records and submits reports assigned by the Manager
• Refers to high-risk cases to the Case Management Department, Government Services Clinical Programs, Fallon Clinic Care Coordination Department and/or other community services according to department protocol
• Collaborates with attending physicians and health care professionals regarding appropriate utilization of medical services
• Identifies utilization issues unique to their team assignment and identifies strategies to address/resolve these issues
• Issues regulatory and other letters according to the department policies and procedures.
  • Electronic copies of all denial letters and related documents are kept in the case management application and/or the organization's security accessed drive(s)
• Acts as a liaison between assigned facilities, members/families, and Fallon Health. Clarify policies/procedures and member benefits as needed. Authorizes services, coordinates care, and ensures timeliness and coordination of healthcare services, in compliance with department and regulatory standards, seeking supplemental services when appropriate or when needed
• Works with Fallon Health providers/support staff and/or members to facilitate cost-effective, quality care
• Requests and obtains relevant clinical information from medical care providers as needed for the clinical review process
• Conducts clinical reviews of proposed services against appropriate criteria/guidelines to determine medical necessity, benefit eligibility, and network contract status
• Refers all cases that do not meet medical necessity, benefit eligibility, and network contract status criteria to a physician reviewer for consideration, ensuring the timely review of the referred case
• Reviews physician reviewers' determinations for appropriateness and completeness
• Communicates determinations to providers and members telephonically and in writing, adhering to corporate/department
• Communicates determinations to providers and members telephonically and in writing, adhering to corporate/department policy and regulatory guidelines.
• Supports Authorization Coordinators in policy and regulatory guidelines
• Supports Authorization Coordinators in identifying alternative services, when appropriate, for denied request, and in communicating alternatives to the requesting provider
• Reviews requests and acts as a resource to Authorization Coordinators; processes and / or consults on authorizations, as appropriate
• Serves as a subject matter expert and point of contact for intradepartmental and interdepartmental inquiries
• Serves as a primary trainer for all UM Nurses on the prior authorization assignment, for new hires and ongoing education needs
• Develops, maintains, and delivers training materials for all UM Nurses on the prior authorization assignment, for new hires and ongoing education needs
• Identifies utilization trends or processes to the Manager, and supports the Manager in the implementation of improvements
• Identifies quality issues and refers outstanding concerns to the Manager for appropriate resolution
• Will check voicemail at regular intervals throughout the day and returns calls/messages within the same day of receipt
• Strictly observes the Fallon Health policies regarding confidentiality of member information, documentation standards, meeting any education requirements, and performs other responsibilities as assigned by department management team

• 2-4 years of 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.
• Excellent computer skills (Microsoft Office, Windows 10, learning new systems with ease).

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.