About Fallon Health:
Founded in 1977, Fallon Health is a leading health care services organization that supports the diverse and changing needs of those we serve. In addition to offering innovative health insurance solutions and a variety of Medicaid and Medicare products, we excel in creating unique health care programs and services that provide coordinated, integrated care for seniors and individuals with complex health needs. Fallon has consistently ranked among the nation’s top health plans, and is accredited by the National Committee for Quality Assurance for its HMO, Medicare Advantage and Medicaid products. For more information, visit www.fallonhealth.org.
Brief summary of purpose:
Performs all functions associated with completing tasks related to inpatient and prior authorization denial letters and special approval letters. This position serves as the subject matter expert on UM letters and works in conjunction with other FH departments including Communications, Customer Service, UM and CM in the maintenance of existing letters and rollout of new letters. Collaborates closely with the UM Clinical and Prior Auth staff to ensure appropriate and applicable language is captured for accuracy, timeliness of appropriate written notification requirements and overall letter integrity. Review and interpret FH and CMS Policies and Procedures to ensure appropriate language is utilized in the letters based on product enrollment. Maintain the quality and timeliness of the letter process and adherence to FH criteria and Medicare guidelines to ensure NQCA compliance
High School Diploma or equivalent. Some advanced education highly preferred.