Prior Authorization Coordinator

Fallon Health•Worcester, MA

About The Position

The Prior Authorization Coordinator administers Fallon Health’s prior authorization processes in accordance with member handbooks and evidence of coverage, departmental policies and procedures, CMS and NCQA standards, and other applicable regulatory requirements. The coordinator serves as a liaison between Fallon Health members and provider offices and Fallon Health, researching, documenting, and resolving authorization issues and completing adjudications in accordance with applicable regulations, policies, and standards. The role includes receiving, screening, entering, researching, and documenting authorizations; approving requests that meet applicable protocols; and preparing requests outside protocol parameters for clinical review, including obtaining supporting records and information from physician offices. The coordinator communicates decisions and instructions to members and providers, answers authorization questions, and works with supervisors, managers, directors, and clinical staff to resolve issues and improve processes. The position also involves telephone and on-site communication, answering calls through an ACD queue as needed, and printing and mailing member notification letters at Fallon Health’s Worcester corporate office several times per month or as directed.

Requirements

High school diploma required.
One to three years of professional experience in a related position, preferably in health care.
Experience in a managed care or call center setting or a physician’s office; knowledge of managed care and/or utilization management strategies is advisable.
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 is helpful.
Experience in health care is preferred.

Responsibilities

Administer authorization processes for all products in accordance with member handbooks and evidence of coverage, internal policies, and applicable regulatory standards.
Meet department turnaround-time and notification standards.
Receive, enter, research, investigate, and document authorizations from intake through notification in QNXT and/or TruCare.
Approve authorizations that meet the applicable Prior Authorization Protocol criteria.
Prepare requests that do not meet protocol parameters for review, contacting physician offices and physicians to obtain records and clinical information and ensuring pertinent information accompanies requests for further review.
Notify members and providers of additional instructions after approval, answer questions, and provide direction and support.
Work with department supervisors, managers, directors, and clinical staff, including Medical Directors, to resolve issues and develop improvement measures and member responses.
Prepare written correspondence to members.
Print and mail member notification letters at the Worcester corporate office several times per month or as needed according to the rotational in-office calendar or supervisor/manager direction.
Accept authorizations, 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 and in accordance with plan quality and service standards.
Communicate by telephone and on-site, as needed, with Fallon Health providers and staff to facilitate the pre-authorization process.