Prior Authorization Service Coordinator - 6 months training in office then flex schedule

Fallon Health•Worcester, MA

22d•Hybrid

About The Position

Fallon Health is a health plan company founded in 1977 in Worcester, Massachusetts, dedicated to providing equitable, high-quality, coordinated care. They are committed to diversity and inclusion, aiming to be a leading provider of government-sponsored health insurance programs. The Prior Authorization Service Coordinator role supports the Manager of Prior Authorization by collecting and disseminating prior authorization request data, initiating data entry into the core system (TruCare), and handling incoming calls from providers and members. This role interprets and triages information to ensure adherence to regulatory standards and maintain the quality and timeliness of the authorization process. The position involves working with various Fallon Health departments to facilitate member services and provider claims.

Requirements

High School Diploma or GED required.
Two+ years office experience, preferably in a managed healthcare environment.
Call center experience helpful.
Knowledge of medical terminology required.
Computer literacy and data entry experience required.
Excellent telephone, typing and computer skills.
Self-starter (able to identify when specifically assigned functions have been completed and to request additional work).
Excellent organizational skills.
Excellent listening/oral communication skills.
Mature judgment: knows when to seek guidance/direction and or when to refer problems to management.
Ability to maintain a high degree of confidential/privileged patient and proprietary business information.
Computer Skills (QNXT, Trucare, Excel, Word).

Nice To Haves

Associates Degree Preferred.
Some advanced education highly preferred.

Responsibilities

Accepts authorization service requests and notifications for FCHP members, screening for eligibility, active insurance coverage, and authorization history.
Initiates entry of requests into the core system (QNXT/TruCare) and case management application (TruCare).
Updates authorization information in QNXT based on determinations made by other team members.
Handles a high volume of daily authorization entries into the core system (QNXT).
Prepares completed authorization records for filing according to company policy.
Assists with the departmental auto fax process, including running error reports.
Generates notifications to members, facilities, and agencies.
Interfaces with other FCHP departments to obtain and verify information relevant to pre-authorization requests.
Distributes departmental facsimiles, checking Right Fax hourly and redirecting/saving as needed.
Manages applicable queues in QNXT UM, Call Tracking, and TruCare.
Enters/extends/changes approved authorizations within established parameters.
Communicates with facilities/agencies/providers to collect data and provide policy information or authorization status.
Communicates with inter/intra-departmental personnel about the authorization process.
Provides first response to inbound calls, handling calls from providers and members with excellent customer service.
Assists FCHP providers, members, and their representatives with authorization-related questions and concerns.
Manages the ACD hunt line and handles calls according to FCHP targets.
Educates PCP offices on new authorization procedures and answers benefit/claims/referral questions.
Manages the Call Tracking module in QNXT.
Strictly observes FCHP policy regarding confidentiality of member and provider information.
Handles other duties as assigned.