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Fallon Health · 1 day ago

RN Director, Utilization Management & Prior Authorization - Hybrid

US-MA-Worcester

Full-time

Hybrid

Senior Level, Lead/Staff

$155K/yr - $175K/yr

10+ years exp

Fallon Health is a company that cares, prioritizing its members to ensure they receive the necessary care. The RN Director of Utilization Management & Prior Authorization will provide strategic leadership and oversight for clinical and operational utilization management activities across all product lines.

FitnessHealth CareMedical

H1B Sponsor Likely

Responsibilities

Oversees all administrative, operational and clinical functions related to outpatient and inpatient, utilization management operations, including but not limited to prior authorization, concurrent review and discharge planning

Ensures that members get the appropriate care that is medically necessary and meets the benefit coverage criteria

Ensures that all reviews meet the appropriate regulatory and accreditation requirements including turnaround times and communication

Ensures program compliance with all federal regulatory and state mandates, Division of Insurance, National Committee for Quality Assurance standards, Centers for Medicare and Medicaid guidance and requirements, MassHealth (Medicaid contractual agreements)

Responsible for hiring appropriate non-physician clinical and non-clinical personnel to review medical cases and determine if requests for services meet medical necessities and criteria for coverage

Oversight of UM by delegated organizations and ensure regulatory and accreditation compliance

Monitors and analysis of operational and outcome data related to all utilization management activities

Recommends and implements innovative process improvements for the prior authorization and utilization management processes

Develops and implements the Utilization Management Program Description and annually evaluate the effectiveness of the program

Represents the UM Department in Program Audits across all LOBs, including information gathering, research, presenting, and development of Corrective Action Plans (if applicable)

Key Contact for RFP responses related to UM Functions and department organization structure/staffing

Works with VP/Medical Director to identify and prioritize the cost of care opportunities related to Utilization Management

Works with VP/ Medical Director to set agenda related to UM and represent the plan at clinical joint operating committees to support collaborative Fallon/provider group relationship

Manages data, predictive analytics to improve efficiency of prior authorization and utilization management

Works with and represents Care Services for utilization management on the different product line task forces at Fallon

Serves as SME and Point of Contact for internal committees including but not limited to Delegation Oversight Committee (DOC), Payment Policy, Mental Health Parity, Medical Directors monthly meeting, and TruCare Insights/upgrade meetings

Represents the Vice President and Senior Medical Director of Clinical Management at internal and external senior level meetings

Budget creation and management of annual budget

Provides UM expertise to Clinical Integration leadership to ensure seamless integrated member care within Care Services as well as other departments by involving inpatient case management with out-patient case management and utilization management to optimize post-acute care

Ensures objectives defined across a broader group are integrated and supportive where necessary

Defines roles and accountabilities for staff, within the group and in the context of the broader process/operation in support of cross-functional efforts

Hires for, develops and recognizes the experience and knowledge/skills/abilities required for a successful team

Provides for the orientation and welcome of new staff

Defines performance expectations and goals for staff

Trains and mentors’ staff on the application of policy and procedures, use of supporting systems/applications, appropriate soft skills: time management, etc

Monitors work of individual staff for efficiency, effectiveness and quality. Provide ongoing constructive feedback and guidance to staff

Evaluates staff on achievement of goals and deliverables and assessment of competencies. Helps staff progress in their careers to the benefit of the department and broader organization. Manages the resolution of performance issues in consultation with Human Resources as appropriate

Qualification

Utilization ManagementRegulatory ComplianceManaged Care ExperienceClinical OperationsData AnalysisStaff DevelopmentLeadershipCommunication SkillsTime ManagementProblem SolvingTeam Collaboration

Required

Master's degree in health administration or business preferred

Bachelor's degree in nursing or related health field required

Massachusetts Nursing Licensure

Broad experience in managed care and/or integrated delivery systems, either payer or provider

Significant experience in regulatory and accreditation compliance requirements for Medicare, Medicaid and the division of insurance support all Fallon Health Products

Experience in managing health care and support personnel, as well as managing health care personnel and external relationships

A comprehensive knowledge of utilization management strategies to manage utilization and costs

Minimum of ten years clinical experience, at least five in managed care or ambulatory clinical operations

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)