Prior Authorization Coordinator

Fallon Health•Worcester, MA

2d•$23 - $24

About The Position

The Prior Authorization Coordinator administers Fallon Health’s prior authorization process in accordance with member handbooks and evidence of coverage, departmental policies and procedures, CMS and NCQA standards, and other applicable regulatory requirements. The role researches, documents, and adjudicates authorization requests within established turnaround-time and notification standards, serving as a liaison between members, provider offices, and Fallon Health. The coordinator reviews requests against prior authorization protocols, approves those that meet criteria, and prepares requests that do not meet protocol parameters for further review with relevant clinical information. The position also supports members and providers with authorization questions and instructions, contributes to resolving cases and improving responses, and periodically prints and mails member notification letters at Fallon Health’s Worcester corporate office.

Requirements

High school diploma required.
1–3 years of professional experience in a related position, preferably in health care.
Excellent writing skills and familiarity and comfort with medical terminology.
Ability to work independently and make appropriate decisions within established business and benefit guidelines.
Excellent interpersonal communication and problem-solving skills.
Excellent research and documentation skills.
Computer literacy, particularly with Windows-based applications, including Word, Excel, PowerPoint, and Access.

Nice To Haves

College degree (B.S. or B.A.) or equivalent preferred.
Medical terminology or medical coding helpful.
Experience in a managed care or call center setting, or in a physician’s office.
Knowledge of managed care and/or utilization management strategies advisable.

Responsibilities

Administer prior authorization processes for all product lines in accordance with member handbooks and evidence of coverage, departmental policies, and applicable regulatory requirements.
Meet department turnaround-time and notification standards.
Enter, research, investigate, and document authorization requests from receipt through notification in QNXT and/or TruCare.
Approve requests that meet the applicable prior authorization protocol and prepare requests outside protocol parameters for further review, obtaining supporting records and clinical information from physician offices and physicians as needed.
Ensure pertinent information accompanies requests sent for further review.
Notify members and providers of additional instructions after approval and answer their questions, providing direction and support.
Work with department supervisors, managers, directors, and clinical staff, including medical directors, to resolve issues; formulate improvement measures and responses to members; and prepare written correspondence to members.
Print and mail member notification letters at the Fallon Health corporate office in Worcester several times per month or as needed, according to the in-office rotation or supervisor/manager direction.
Accept authorization requests, screen member eligibility, and enter information into the Fallon Health Core system.
Answer authorization questions from members and providers as needed.
Answer telephone calls through the ACD queue as needed, meeting the plan’s quality and service standards.
Communicate by telephone and on-site with Fallon Health providers and staff as needed to facilitate the pre-authorization process.