Overview

The Prior Authorization Letter Writer position works M - F 8 am to 5 pm/ 8:30 am to 5 pm and will require at least 6 months of training 5 days/week in the Worcester office and then will require 2 days/week in the office and 3 days/week at home. This position needs someone well versed in managed care and prior authorizations.

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:

Performs all functions associated with completing tasks related to inpatient and prior authorization denial letters and special approval letters. This position serves as the subject matter expert on UM letters, and works in conjunction with other FH departments including Communications, Customer Service, UM and CM in the maintenance of existing letters and rollout of new letters. Collaborates closely with the UM Clinical and Prior Auth staff to ensure appropriate and applicable language is captured for accuracy, timeliness of appropriate written notification requirements and overall letter integrity. Review and interpret FH, MassHealth, and CMS Policies and Procedures to ensure appropriate language is utilized in the letters based on product enrollment. Maintain the quality and timeliness of the letter process and adherence to FH criteria, MassHealth, and CMS guidelines to ensure NQCA and regulatory compliance.

Responsibilities

Primary Job Responsibilities:

• Utilizing knowledge from processing inpatient and/or prior authorization requests, complete all tasks required to produce, issue, and retain a timely and accurate written notification to the member and provider while adhering to regulatory and contractual requirements for content, structure, reading level, etc.
• Written notifications include approval and denial letters for Acute Inpatient, Post-Acute, Elective Inpatient, and Outpatient
• Completion of all denial letters and special approval letters for Prior Auth requests
• Perform spell check and grammar check for appropriate sentence structure to ensure letter accuracy
• Critically review letters to ensure that denial reasons, which may include complex medical information, are composed accurately and in a member-friendly manner with attention to reading levels
• Collaborate with internal stakeholders to ensure integrity of letters
• Maintain letter inventory, and ensure letters are current, appropriate, and compliant with CMS, MassHealth, DOI regulations and contracts
• Periodic review of all letter templates to ensure that letters reflect current regulations and remain accurate in face and tone
• Coordinate the approval of any new letter, revisions or annual updates with the Communications department
• Serve as a SME for the Department for letter maintenance, and projects implementations
• Participate as a SME for the Department in both internal and external audits’ file review

Qualifications

Education:

Bachelor's Degree or equivalent experience

Experience:

• 3 years’ experience, preferably in a managed healthcare environment, with prior authorization and utilization management processes and procedures
• Ability to review and interpret regulatory-governed documents and medical terminology, and condense said language into a member-friendly letter
• Ability to maintain and manage document inventory across multiple products
• Ability to maintain high degree of confidential/privileged patient and proprietary business information
• Ability to work in fast paced environment
• Familiarity with or ability to become familiar with governmental regulations and accrediting agency health plan requirements.
• Excellent organizational skills
• Excellent written communication skills
• Strong computer skills (QNXT, TruCare, Microsoft Office Word)
• Self-starter (able to identify when specifically assigned functions have been completed and to request additional work)

Reources:

TruCare, QNXT, Microsoft Word

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.

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