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:

The Manager, Prior Authorization RN manages all staffing and activities related to prior authorization which includes but is not limited to preservice, concurrent and retrospective reviews for medical necessity or benefit review. Along with other members of the medical management leadership team, the Manager is responsible for the quality and cost effectiveness of care provided to Fallon Health (FH) members. Specific responsibilities include:

• Ensures that accurate, timely information for all Members requiring prior authorization is captured and disseminated to appropriate staff daily.
• Utilizes approved FH criteria in addition to InterQual, MassHealth and Medicare guidelines when completing outpatient authorization reviews such as Home Health, DME, genetics, ambulatory surgical procedures
• Ensures that appropriate, timely turnaround times are met
• Creates and disseminates all required utilization reports on a daily, monthly, quarterly and annual basis.
• Maintains appropriate staffing levels for the PA Team.
• Responsible for the ongoing development and implementation of new strategies, processes, policies and procedures related to the PA/UM program ensuring compliance with governmental, accrediting agency and health plan requirements.
• Meets departmental utilization and budgetary goals on a monthly, quarterly and annual basis.
• Supports plan accreditation efforts as they related to Prior Authorization UM.
• Oversees all activities of the Supervisor, PA RN and their direct and indirect reports
• Functions independently and generally establishes own work plan and priorities, using and / or modifying established procedures, to assure timely completion of assigned work in conformance with established departmental policies and standards; problems lacking clear precedent are usually reviewed with the Director, UM and PA prior to taking action.

Primary Responsibilities:

• 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.
• Manages the daily operations of the Prior Authorization Unit, including the authorization turnaround time in accordance with regulatory timeframes.
• 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 PA/UM (TruCare) application as required. Represents the department as needed, in internal and external meetings, on behalf of the Director, as needed.
• Becomes the SME to work collaboratively with other member-facing internal departments, such as NaviCare, ACO, OP Case Management, and Fallon’s contracted vendors to ensure members have access to timely, appropriate, quality care, representing the department, if needed, in internal and external meetings
• Acts as a resource and educator for the prior authorization clinical team to resolve administrative and clinical issues that arise during the outpatient authorization review process (OP auth’s include, but are not limited to: Home Health, DME, genetics, ambulatory surgical procedures).
• Ensure that nursing staff are prepared and able to present enrollee data during rounds and huddles appropriately, teaching and mentoring as appropriate.
• Ensure that  nursing staff are able to apply ocverage criteria in an appropriate manner.
• Supports department colleagues, covering and assuming changes in assignment.
• Develops, creates, and disseminates reports to effectively manage and continuously improve the Prior Authorization functions.
• Identifies reporting needs to the Business Intelligence Unit for enhanced monitoring of Prior Authorization productivity and performance.
• Creates, implements and/or updates PA Policies and Procedures as necessary or required for UCSC yearly evaluation basis with attention to NCQA, Medicare, MassHealth, DOI standards and regulatory requirements.
• Monitors the regulatory reports and other utilization reports for adherence to regulatory requirements and inconsistencies, then works with staff on re-education when needed.
• 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, Home Health Agencies, etc.) to ensure appropriate service is delivered to Fallon Health members.
• Attends FH committee meetings as assigned by the Director of UM and PA, such as TruCare Production meetings, Authorization Automation development meetings, report development meetings with IT, Claims edit meetings, etc.
• Assist in development and writing of required documents for Authorization 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 authorization 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 Director of UM and PA or their designee based on the needs of the business.
• Interact with internal departments (NC/CM/ACO) to ensure service requests are being considered in a holistic way to meet the members needs, consulting with leaders, as needed to make authorization decisions, then ensuring direct reports are doing the same.
• Oversee all functions of the Supervisor, PA RN related to:
  • HR issues with staff
  • Staff education
  • IRR,
  • training
  • compliance
  • performance evaluation(s)
  • TAT measures
  • Specialized skill sets
  • Staff special project completion
  • Quality audit reviews of authorizations
  • Updates to Medicare/Medicaid regulatory rules
  • Authorization documentation standards

Education:

Graduate from an accredited school of nursing or Bachelor's (or advanced) degree in nursing.  Experience in a managed care or healthcare setting preferred.

License/Certifications:

Active, unrestricted license as a Registered Nurse In Massachusetts

Experience:

• A minimum of three to five years’ clinical experience as a Registered Nurse, in a clinical setting required.
• Minimum of three to five years’ experience as a utilization nurse in a payer or facility setting highly preferred.
• Discharge planning experience preferred.
• Experience in outpatient authorization processing (including Home Health Care, DME, genetics, ambulatory surgery) highly preferred
• Experience in regulatory requirements in a payor or facility setting highly preferred (NCQA, DOI, CMS, Medicare, MassHealth)
• Experience in claims processing against authorization status highly preferred
• Experience with managed care plan benefits, Medicare and Medicaid coverage criteria requirements required
• Experience developing policies, procedures, and workflows preferred
• Experience with performance improvement projects including but not limited to establishing criteria for report queries, utilizing objective data to improve processes, and implementation of projects preferred
• Ensuring team performance goals are met and ensuring program staff are trained and compliant with departmental and policy requirements
• Educating direct reports on various levels of prior authorization interventions and recommending and supporting team actions to ensure effective resolution of authorization requests – active participant in Clinical Rounds
• Experience in a payer setting, managed care preferred.
• Excellent verbal and written communication/presentation skills, and ability to interact with all levels of staff and leadership
• Demonstrated leadership and team management skills.
• Ability to analyze, synthesize and effectively communicate information.

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.

#P02