Fallon Health

  • Manager, Prior Authorization

    Location US-MA-Worcester
    Posted Date 1 month ago(1/17/2019 1:44 PM)
    Job ID
    # Positions
    Care Coordination
  • Overview

    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 fallonhealth.org.

    Brief Summary of Purpose:

    Manages the daily operations of the Prior Authorization Unit; responsible for developing and implementing processes that enhance the efficiency and effectiveness of the Prior Authorization Program. Becomes involved in key FH committees which have any impact on the authorization process. Becomes the subject matter expert (SME) for the Trucare application and regulatory reports as required. Represents the Senior Director of IUM when necessary.


    • Works with appropriate Fallon Health (FH) units / departments and Physicians to automate and streamline the authorizations’ process through continuous monitoring and implementation of telephonic review and electronic authorization processes. 
    • Works with Senior Director of department to identify opportunities of improvement and/or efficiency such as codes/services that may not require authorization and bring them up to TAC for review/assessment. 
    • Hires, orients, supervises and evaluates staff that functions within the Unit; establishes goals with staff and evaluates performance based on established goals; conducts staff meetings on a regular basis. 
    • Evaluates staffing and budget needs to ensure that the day-to-day operations of the Unit are carried out appropriately and efficiently. 
    • Develops reports to effectively manage and continuously improve the Program; creates reports to identify and document productivity, turnaround times, authorization volumes by region and compliance with regulatory standards; provides feedback and education to staff as warranted. 
    • Develops audit processes to ensure authorization quality, performance and decision consistency. 
    • Acts as a resource and educator for the Unit; educates staff on all regulatory changes.    
    • Develops and conducts education / training sessions regarding the Prior Authorization Process to FH internal and external customers. 
    • Establishes productivity and goals with staff and evaluates performance based on these defined goals. 
    • Conducts staff meetings on a regular basis. 
    • Meets 1:1 with assigned staff on a regular basis.
    • Evaluates staffing and operational needs to ensure that the day-to-day operations of the Unit are carried out in compliance with Departmental and health plan budgetary requirements.
    • Develops, creates, and disseminates reports to effectively manage and continuously improve the Prior Auth functions. 
    • Creates reports to monitor Prior Auth productivity and performance. 
    • Creates, implements and/or updates UM Policies and Procedures as necessary or required for UCSC yearly evaluation. 
    • Responds to customer concerns and / or feedback and uses this information to further refine internal processes. 
    • Interfaces and resolves issues with contracted and non-contracted vendors for all ancillary care (e.g., home health, DME, Infusion Therapy, Outpatient Rehab Facilities, etc.) to ensure appropriate service is delivered to Fallon Health members. 
    • Attends FH committee meetings as assigned by Sr. Director of IUM, such as Trucare Production meetings, Auth Automation development meetings, report development meetings with IT, Claims edit meetings, etc.
    • Assist in development and writing of required documents for Auth Automation and downstream impacted areas including but not limited to reporting and training of internal and external entities.
    • Be the contact person for internal customers with auth related issues, including but not limited to Sales, Claims, Provider Relations, Communications, Appeals and Case Management.  
    • Strictly observes the HIPPA regulations and the FH policy regarding confidentiality of member information. 
    • Performs other duties or responsibilities as assigned by the Sr. Director of the department or VP of Clinical Operations based on the needs of the business.



    Bachelor’s degree or higher, preferably in focus on healthcare administration, communications or business.



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