Fallon Health · 1 month ago
Temporary to Hire Prior Authorization RN - Hybrid Remote
US-MA-Worcester
Full-time
Hybrid
Mid, Senior Level
3+ years expFallon Health is a company that cares, focusing on delivering high-quality, coordinated care to its members. The Prior Authorization RN is responsible for reviewing service requests and ensuring high quality, cost-efficient medical outcomes for enrollees by collaborating with various healthcare professionals and adhering to regulatory guidelines.
FitnessHealth CareMedical
Responsibilities
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 as assigned by the Manager
Refers high-risk cases to the appropriate FH internal teams (ie: Outpatient Case Management, NaviCare, ACO) and/or other community services according to department protocol
Collaborates with attending physicians and health care professionals regarding appropriate utilization of medical services
Completes level of care/service request reviews strictly adhering to regulatory turnaround time guidelines such as, but not limited to, CMS, NCQA, and the DOI
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 Fallon Health core application and/or the organization’s security accessed drive(s)
Acts as a liaison between Providers, vendors, facilities, members/families, and Fallon Health internal departments. Clarifies 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 pre-authorization and concurrent clinical reviews requests for services such as DME, elective procedures, Home Health Care, Out of network specialty care, transportation and genetics, 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
Incrementally monitors the effectiveness of established plans of care with defined, measurable goals and objectives and cost-benefit documentation as applicable and modifies the care plan when applicable
Streamlines the focus of the member’s healthcare needs utilizing the most optimal treatment approach, promoting timely provision of care, enhancing quality of life, and promoting cost-effectiveness of care
Analyzes and applies CMS always INPT and SDS CPT codes during PA clinical reviews when a surgical procedure is requested as IP LOC
Collaborates with Fallon Health departments to ensure services/items needed to facilitate discharge from a post-acute or hospital setting do not delay discharge
Collaborate with external providers on alternative coverage options when services requested do not meet medical necessity, benefit eligibility, and network contract status criteria
Creates contingency plans for each step of the process to anticipate treatment and service complications, while ensuring that the member attains pre-determined outcomes
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
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
Participates in weekly medical rounds with the leadership team, Medical Directors, and various Fallon Health departments to discuss patient issues and/or concerns. Organizes and presents complex medical cases in a clear and concise oral and written manner
Ensures ad hoc contracts are in place for non-contracted services working in conjunction with FH Network Development team
Qualification
Required
Graduate from an accredited school of nursing, Associate's Degree, Bachelors Degree, or advanced degree in nursing required
Active and unrestricted licensure as a Registered Nurse in Massachusetts
A minimum of three to five years clinical experience as a Registered Nurse in a clinical setting required
Preferred
2 years' experience as a Utilization Management/Prior Authorization nurse in a managed care payer preferred
One year experience as a case manager in a payer or facility setting highly preferred
Relevant experience may include but not be limited to experience working directly in the field of Home Health Care, Ambulatory Provider Setting, Rehabilitation Nursing Setting, Acute Hospital Setting
Relevant experience may include, but not be limited to experience processing authorizations for services such as: Home Health Care, DME, Ambulatory Procedures, Genetic Testing, Pharmacy, Nutritional supplies, Acute Hospital Level of Care, Post-Acute level of care reviews (SNF, Acute Rehab, Long Term Acute Care)
Company
Fallon Health
Founded in 1977, Fallon Health is a community-focused not-for-profit health care services organization based in Worcester, Massachusetts.
1001-5000 employees
H1B Sponsorship
Fallon Health has a track record of offering H1B sponsorships. Please note that this does not
guarantee sponsorship for this specific role. Below presents additional info for your
reference. (Data Powered by US Department of Labor)
Distribution of Different Job Fields Receiving Sponsorship
Represents job field similar to this job
Trends of Total Sponsorships
2025 (8)
2024 (8)
2023 (5)
2022 (9)
2021 (7)
2020 (5)
Funding
Current Stage
Late StageLeadership Team
Dorothy Vandette
Manager, CEO Office
Todd Bailey
Senior Vice President, Chief Financial Officer
Recent News
2026-01-09
2025-08-07
2025-06-07
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