Utilization Management Coordinator
Company: Fallon Community Health Plan
Location: Worcester
Posted on: May 15, 2022
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Job Description:
Utilization Management CoordinatorUS-MA-WorcesterJob ID:
6732Type: Full Time# of Openings: 1Category: Customer ServiceFallon
Health - Corp HQOverviewService Coordinator - Several Openings and
Always Growing! Fallon Health Vaccination Requirements:To protect
the health and safety of our workforce, members and communities we
serve, Fallon Health now requires all employees to disclose
COVID-19 vaccination status. As of 2/1/2022 all roles not
designated as "Remote" require full COVID-19 vaccination and Fallon
Health will obtain the necessary information from candidates prior
to employment to ensure compliance. Failure to meet the vaccination
requirement may result in rescission of an employment offer or
termination of employment. About 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 Fallon Health 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 Fallon Health 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.CommunicationsCommunicates with contracted
and non-contracted facilities/agencies/providers to collect
pertinent data regarding an episode of care and give applicable
policy information and/or authorization numbers and status to
facility/agency. Communicates with inter/intra departmental
personnel with regard to all aspects of the authorization process
as requested.Responsible to provide first response to inbound call
center. Handles calls from providers and members with excellent
customer service. Assist Fallon Health providers, members and/or
their recognized authorized representatives with questions and
concerns regarding authorizations.Manage the ACD hunt line and
handle calls appropriately with a focus toward excellent customer
service. In addition the Service Coordinator will attain the
targets for a customer service call center as set by Fallon Health.
These targets will be communicated to the staff by the
Manager.Educates PCP offices on new authorization procedures as
needed as well as answer benefit/claims/referral questions in
support of the Customer Service function.Manage the Call Tracking
module in the core system (QNXT) as required.MiscellaneousStrictly
observes the Fallon Health policy regarding confidentiality of
member and provider information. Handle other duties as assigned
based on the needs of the business.QualificationsEducation:
Associates Degree Preferred. Some advanced education highly
preferred..Experience: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 skillsSelf-starter (able to identify when specifically
assigned functions have been completed and to request additional
work)Excellent organizational skillsExcellent listening/oral
communication skillsMature judgment: knows when to seek
guidance/direction and or when to refer problems to
managementAbility to maintain high degree of
confidential/privileged patient and proprietary business
informationComputer Skills (QNXT, Trucare, Excel, 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. PM16PI177593841
Keywords: Fallon Community Health Plan, Worcester , Utilization Management Coordinator, Executive , Worcester, Massachusetts
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