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 PA Nurse uses a multidisciplinary approach to review service requests (prior-authorizations), focusing on selected complex medical and psychosocial needs of FH members and their families.  The PA Nurse is responsible for assuring the receipt of high quality, cost efficient medical outcomes for enrollees. This role works with Medical Directors, Authorization Coordinators, and Service Coordinators to perform pre-service, concurrent, and retrospective reviews for outpatient services such as elective procedures, home health care, DME, nutrition, and genetic testing utilizing established state, federal, and internally developed benefit and clinical coverage criteria against FH polices and protocols. Medical necessity determinations are reviewed with the holistic picture of the member in mind, which requires exceptional attention to detail, proficiency in applying correct criteria, and collaboration with internal and external partners.

Primary Job Responsibilities

• Obtain clinical, functional, and psychosocial information from the medical records on site, through remote electronic access, telephonically or by fax in a collaborative effort with other health care professionals, member and/or family
• Refers cases to medical review according to policy and procedure
• Documents clinical, functional, psychosocial information in the Core System as well as communications regarding the members’ care
• Keeps records and submits reports as assigned by the Manager
• Refers high-risk cases to the appropriate FH internal teams (ie: Outpatient Case Management, NaviCare, ACO) and/or other community services according to department protocol
• Collaborates with attending physicians and health care professionals regarding appropriate utilization of medical services
• Completes level of care/service request reviews strictly adhering to regulatory turnaround time guidelines such as, but not limited to, CMS, NCQA, and the DOI
• Identifies utilization issues unique to their team assignment and identifies strategies to address/resolve these issues
• Issues regulatory and other letters according to the department policies and procedures.
• Electronic copies of all denial letters and related documents are kept in the Fallon Health core application and/or the organization’s security accessed drive(s)
• Acts as a liaison between Providers, vendors, facilities, members/families, and Fallon Health internal departments. Clarifies policies/procedures and member benefits as needed. Authorizes services, coordinates care, and ensures timeliness and coordination of healthcare services, in compliance with department and regulatory standards, seeking supplemental services when appropriate or when needed
• Works with Fallon Health providers/support staff and/or members to facilitate cost-effective, quality care
• Requests and obtains relevant clinical information from medical care providers as needed for the clinical review process
• Conducts pre-authorization and concurrent clinical reviews requests for services such as DME, elective procedures, Home Health Care, Out of network specialty care, transportation and genetics, against appropriate criteria/guidelines to determine medical necessity, benefit eligibility, and network contract status
• Refers all cases that do not meet medical necessity, benefit eligibility, and network contract status criteria to a physician reviewer for consideration, ensuring the timely review of the referred case
• Incrementally monitors the effectiveness of established plans of care with defined, measurable goals and objectives and cost-benefit documentation as applicable and modifies the care plan when applicable.
• Streamlines the focus of the member’s healthcare needs utilizing the most optimal treatment approach, promoting timely provision of care, enhancing quality of life, and promoting cost-effectiveness of care.
• Analyzes and applies CMS always INPT and SDS CPT codes during PA clinical reviews when a surgical procedure is requested as IP LOC
• Collaborates with Fallon Health departments to ensure services/items needed to facilitate discharge from a post-acute or hospital setting do not delay discharge
• Collaborate with external providers on alternative coverage options when services requested do not meet medical necessity, benefit eligibility, and network contract status criteria
• Creates contingency plans for each step of the process to anticipate treatment and service complications, while ensuring that the member attains pre-determined outcomes
• Reviews physician reviewers’ determinations for appropriateness and completeness
• Communicates determinations to providers and members telephonically and in writing, adhering to corporate/department Communicates determinations to providers and members telephonically and in writing, adhering to corporate/department policy and regulatory guidelines
• Will check voicemail at regular intervals throughout the day and returns calls/messages within the same day of receipt
• Strictly observes the Fallon Health policies regarding confidentiality of member information, documentation standards, meeting any education requirements, and performs other responsibilities as assigned by department management team
• Participates in weekly medical rounds with the leadership team, Medical Directors, and various Fallon Health departments to discuss patient issues and/or concerns. Organizes and presents complex medical cases in a clear and concise oral and written manner
• Ensures ad hoc contracts are in place for non-contracted services working in conjunction with FH Network Development team

Education

• Graduate from an accredited school of nursing, Associate’s Degree, Bachelors Degree, or advanced degree in nursing required

License/Certifications

• Active and unrestricted licensure 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.
• 2 years’ experience as a Utilization Management/Prior Authorization nurse in a managed care payer preferred.
• One year experience as a case manager in a payer or facility setting highly preferred.
• Relevant experience may include but not be limited to experience working directly in the field of Home Health Care, Ambulatory Provider Setting, Rehabilitation Nursing Setting, Acute Hospital Setting.
• Relevant experience may include, but not be limited to experience processing authorizations for services such as:

Outpatient authorization requests such as:

• Home Health Care
• DME
• Ambulatory Procedures
• Genetic Testing
• Pharmacy
• Nutritional supplie

Inpatient authorization requests such as:

• Acute Hospital Level of Care
• Post-Acute level of care reviews (SNF, Acute Rehab, Long Term Acute Care

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.