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Fallon Health · 3 days ago

Prior Authorization Coordinator

US-MA-Worcester

Full-time

Onsite

Entry Level

1+ years exp

Fallon Health is a company dedicated to providing high-quality, coordinated care and is recognized for its exceptional member experience. The Prior Authorization Coordinator plays a crucial role in managing the authorization process to ensure compliance with regulatory standards while serving as a liaison between members and provider offices.

FitnessHealth CareMedical

Responsibilities

Administers FH authorization processes as outlined in Member Handbook/Evidence of Coverage for all products, and in compliance with applicable CMS and NCQA standards and other state or federal regulatory requirements. Strictly adheres to department turn-around time standards established in accordance with regulatory standards

Enters, researches, investigates, and documents all authorizations from receipt to notification into QNXT and/or TruCare for all product lines

Approves authorizations when the authorization meets the criteria listed in the appropriate Prior Authorization Protocol, authorizations not meeting protocol parameters are prepared for review, including direct contact with physician’s offices and physicians to obtain records and other clinical information in support of the request; ensures that all pertinent information accompanies requests for further review

Notifies members and providers of any additional instructions necessary once authorization approval has been obtained from the reviewers; answers questions and provides direction and support

Works with Department Supervisors, Manager and/or Director, or Clinical Staff including the Medical Directors to resolve issues; formulates improvement measures and response to members; prepares written correspondence to members

Print and mail member notification letters at the FH corporate office located at 10 Chestnut Street, Worcester, MA several times per month or as needed, as designated through a rotational in-office calendar or at the direction of a supervisor or manager

Adheres to department standards for completion of authorization turn-around time and notification

Accepts authorizations for FH members, screens for member eligibility and enters information into the FH Core system

Answers authorization questions from members and providers, as needed

Answers telephone calls via ACD queue, as needed, within the Plan’s standards for quality and service

Communicates both by telephone and on-site, as needed, with FH providers and staff to facilitate the Pre-Authorization Process

Qualification

Prior Authorization ProcessMedical TerminologyManaged Care KnowledgeResearch SkillsDocumentation SkillsComputer LiteracyInterpersonal CommunicationProblem-Solving SkillsWriting Skills

Required

High School Diploma

1-3 years 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

Computer literate, particularly in Windows based applications (Word, Excel, PowerPoint, and Access)