About us:

Fallon Health is a company that cares. We prioritize our members—always—making sure they get the care they need and deserve. Founded in 1977 in Worcester, Massachusetts, Fallon Health delivers equitable, high-quality, coordinated care and is continually rated among the nation’s top health plans for member experience, service, and clinical quality. We believe our individual differences, life experiences, knowledge, self-expression, and unique capabilities allow us to better serve our members. We embrace and encourage differences in age, race, ethnicity, gender identity and expression, physical and mental ability, sexual orientation, socio-economic status, and other characteristics that make people unique. Today, guided by our mission of improving health and inspiring hope, we strive to be the leading provider of government-sponsored health insurance programs—including Medicare, Medicaid, and PACE (Program of All-Inclusive Care for the Elderly)— in the region. Learn more at fallonhealth.org or follow us on Facebook, Twitter and LinkedIn.

Brief Summary of Purpose: 

Performs all functions associated with completing tasks related to inpatient and outpatient prior authorization 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 letter templates and rollout of new letter templates for all lines of business. Collaborates closely with the Prior Auth Clinical and non-clinical operational staff to ensure appropriate and applicable language is captured for accuracy, timeliness of appropriate written notification requirements and overall letter integrity. Ensure all areas of the letter template are completed prior to being delivered to members, authorized representatives, and providers. Maintain the quality and timeliness of the letter process and adherence to FH criteria, MassHealth, and CMS guidelines to ensure NQCA and regulatory compliance.

Primary Job Responsibilities: 

• Complete all tasks required to produce, issue, and retain a timely and accurate written notification to the member and provider while adhering to regulatory and contractual requirements for content, structure, reading level, etc.
• Written notifications include approval/denial and other letters for Outpatient services.
• Completion of all denial/approval and other letters for Prior Auth requests will require monitoring queues and reporting (Alteryx, Clarity, TruCare)
• Perform spell check and grammar check as well as auth review to ensure determination, appropriate sentence structure and letter accuracy.
• Collaborate with internal stakeholders to ensure integrity of letters
• Maintain letter inventory, and ensure letters are current, appropriate, and compliant with CMS, MassHealth, DOI regulations and contracts
• Periodic review of all letter templates to ensure that letters reflect current regulations and remain accurate in face and tone
• Coordinate the approval of any new letter, revisions or annual updates with the Communications department
• Serve as a SME for the Department for letter maintenance, and projects implementations
• Participate as a SME for the Department in both internal and external audit file reviews
• Clear and professional communicator, as outreach to providers may be necessary to obtain updated contact information.
• Proficient in computer systems and applications and comfortable navigating various software and digital platforms.
• Ensure updated letter templates, maintained on the Fallon Health Operational Letter website are forwarded to all FH delegated vendors for use

Education:

High School Diploma advanced degree or equivalent experience preferred

License/Certifications: 

N/A

Experience: 

• 1 year experience, preferably in a managed healthcare environment
• Ability to maintain and manage document inventory across multiple products
• Ability to maintain high degree of confidential/privileged patient and proprietary business information
• Ability to work in fast paced environment
• Familiarity with or ability to become familiar with governmental regulations and accrediting agency health plan requirements. 
• Excellent organizational skills
• Excellent written communication skills
• Strong computer skills (QNXT, TruCare, Microsoft Office Word)
• Self-starter (able to identify when specifically assigned functions have been completed and to request additional work)

Fallon Health provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.