Services Coordinator - Utilization Management
Company: Fallon Community Health Plan
Location: Worcester
Posted on: January 14, 2021
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Job Description:
Services Coordinator - Utilization ManagementUS-MA-WorcesterJob
ID: 6153Type: Full Time# of Openings: 1Category: Customer
ServiceFallon Health - Corp HQOverviewAbout Fallon HealthFounded in
1977, Fallon Health is a leading health care services organization
that supports the diverse and changing needs of those we serve. In
addition to offering innovative health insurance solutions and a
variety of Medicaid and Medicare products, we excel in creating
unique health care programs and services that provide coordinated,
integrated care for seniors and individuals with complex health
needs. Fallon has consistently ranked among the nation's top health
plans, and is accredited by the National Committee for Quality
Assurance for its HMO, Medicare Advantage and Medicaid products.
For more information, visit fallonhealth.org.Brief summary of
purpose:Under the direction of the Manager IUM Prior Authorization,
communicates with contracted and non-contracted
facilities/agencies/providers to collect pertinent prior
authorization request data and disseminates information to the
Authorization Coordinators. Additionally, supports the
authorization process by receiving incoming
faxed/mailed/emailed/etc. requests and initiates entry of service
request shells into core system (QNXT) and TruCare. Responsible for
incoming calls from the multiple ACD lines for the UM department
addressing and/or referring customer (provider/member)
calls/inquiries, provide direction regarding Plan policies,
procedures and when applicable, benefit information. Work in
conjunction with other FCHP departments to assist in processing
authorization information in order to facilitate the member's
medical services or the providers' claims. Interprets and triages
information to ensure appropriate action is initiated to meet
regulatory bodies' standards and to maintain the quality and
timeliness of the authorization process. Responsibilities
Authorization FunctionsAccepts authorization service requests and
notifications for FCHP members, screens for member eligibility,
additional active insurance coverage and authorization history from
the core system. Initiates entry of request(s) into core system
(QNXT/TruCare) and case management application (TruCare) as
applicable.Updates authorization information in QNXT as a result of
determinations made by Authorization Coordinators, Nurse Reviewers
and/or Nurse Care Specialists.Handles an appropriately high volume
of daily auth entries into the core system (QNXT). This volume
target will be communicated to the staff on a regular basis by the
Manager as business needs dictate. Prepares completed authorization
records for filing in accordance with company record retention
policy. Assists with departmental auto fax process including
running error reports and missing Fax # report on a daily basis as
assigned.Generates notifications to members, facilities and
agencies according to established protocol (auto-fax notification
process and auto-generated letter process from the core
systemInterfaces with other FCHP departments to obtain and verify
information relevant to pre-authorization requests (e.g. contract
information, benefits, etc.), including authorization details when
requested for Appeals.Distributes departmental facsimiles; checks
Right Fax no less than hourly throughout the day; follows
established process for determining to whom facsimiles are to be
delivered; researches facsimiles inappropriately addressed by using
the core system (QNXT) or by communicating with appropriate
individuals for assistance; redirects/saves facsimiles as indicated
to the staff and/or G drive.Manage applicable queues in both the
core system (QNXT UM and Call Tracking) and the case management
application (TruCare).Enters/extends/changes approved
authorizations within established parameters.Communications
Keywords: Fallon Community Health Plan, Worcester , Services Coordinator - Utilization Management, Executive , Worcester, Massachusetts
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