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Fallon Health · 1 day ago

Prior Auth Service Coordinator

US-MA-Worcester

Full-time

Onsite

Entry Level

$21/hr - $22/hr

2+ years exp

Fallon Health is a company that cares, prioritizing their members to ensure they receive the care they need. The Prior Auth Service Coordinator role involves managing prior authorization requests, communicating with providers, and ensuring the quality and timeliness of the authorization process.

FitnessHealth CareMedical

H1B Sponsor Likely

Responsibilities

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 because 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 daily 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; research 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 about 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

Qualification

QNXTTruCareMedical terminologyData entryCustomer serviceComputer literacyOrganizational skillsCommunication skills

Required

High School Diploma or GED required

Two+ years office experience, preferably in a managed healthcare environment

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)

Preferred

Associates Degree Preferred

Some advanced education highly preferred

Call center experience helpful

Company

Fallon Health

Founded in 1977, Fallon Health is a community-focused not-for-profit health care services organization based in Worcester, Massachusetts.

Founded in 1977

Worcester, Massachusetts, USA

1001-5000 employees

http://www.fchp.org

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)