Letter Writer Prior Authorization Health Insurance Flexible Remote 3 Days Onsite

Company: Fallon Health
Location: Worcester
Posted on: September 2, 2024

Job Description:

Overview:About us:Fallon Health is a company that cares. We prioritize our membersalwaysmaking 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 nations 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 programsincluding 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.3 days in the office** Prior Authorization experience required**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 OutpatientCompletion of all denial letters and special approval letters for Prior Auth requestsPerform spell check and grammar check for appropriate sentence structure to ensure letter accuracyCritically 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 levelsCollaborate with internal stakeholders to ensure integrity of lettersMaintain letter inventory, and ensure letters are current, appropriate, and compliant with CMS, MassHealth, DOI regulations and contractsPeriodic review of all letter templates to ensure that letters reflect current regulations and remain accurate in face and toneCoordinate the approval of any new letter, revisions or annual updates with the Communications departmentServe as a SME for the Department for letter maintenance, and projects implementationsParticipate as a SME for the Department in both internal and external audits file reviewQualifications:Education:Bachelor's Degree or equivalent experienceExperience:3 years experience, preferably in a managed healthcare environment, with prior authorization and utilization management processes and proceduresAbility to review and interpret regulatory-governed documents and medical terminology, and condense said language into a member-friendly letterAbility to maintain and manage document inventory across multiple productsAbility to maintain high degree of confidential/privileged patient and proprietary business informationAbility to work in fast paced environmentFamiliarity with or ability to become familiar with governmental regulations and accrediting agency health plan requirements.Excellent organizational skillsExcellent written communication skillsStrong 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 WordCOVID-19 Vaccination:With the end of the Global Coronavirus COVID-19 Pandemic, Fallon Health no longer requires all employees to be vaccinated against COVID-19 except for employees who are in jobs that under state and federal laws, regulations and policies are required to be vaccinated and/or they are in Member/participant facing positions.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.#P01by Jobble

Keywords: Fallon Health, Worcester , Letter Writer Prior Authorization Health Insurance Flexible Remote 3 Days Onsite, Healthcare , Worcester, Massachusetts