Fallon Health
Manager, Prior Authorization RN
The Manager, Prior Authorization RN manages all staffing and activities related to prior authorization which includes but is not limited to preservice, concurrent and retrospective reviews for medical necessity or benefit review. Along with other members of the medical management leadership team, the Manager is responsible for the quality and cost effectiveness of care provided to Fallon Health (FH) members. Specific responsibilities include: Ensures that accurate, timely information for all members requiring prior authorization is captured and disseminated to appropriate staff daily. Utilizes approved FH criteria in addition to InterQual, MassHealth and Medicare guidelines when completing outpatient authorization reviews such as Home Health, DME, genetics, ambulatory surgical procedures. Ensures that appropriate, timely turnaround times are met. Creates and disseminates all required utilization reports on a daily, monthly, quarterly and annual basis. Maintains appropriate staffing levels for the PA Team. Responsible for the ongoing development and implementation of new strategies, processes, policies and procedures related to the PA/UM program ensuring compliance with governmental, accrediting agency and health plan requirements. Meets departmental utilization and budgetary goals on a monthly, quarterly and annual basis. Supports plan accreditation efforts as they related to Prior Authorization UM. Oversees all activities of the Supervisor, PA RN and their direct and indirect reports. Functions independently and generally establishes own work plan and priorities, using and / or modifying established procedures, to assure timely completion of assigned work in conformance with established departmental policies and standards; problems lacking clear precedent are usually reviewed with the Director, UM and PA prior to taking action. Qualifications
Education: Graduate from an accredited school of nursing or Bachelor's (or advanced) degree in nursing. Experience in a managed care or healthcare setting preferred. License/Certifications: Active, unrestricted license as a Registered Nurse In Massachusetts Experience: A minimum of three to five years' clinical experience as a Registered Nurse, in a clinical setting required. Minimum of three to five years' experience as a utilization nurse in a payer or facility setting highly preferred. Discharge planning experience preferred. Experience in outpatient authorization processing (including Home Health Care, DME, genetics, ambulatory surgery) highly preferred Experience in regulatory requirements in a payor or facility setting highly preferred (NCQA, DOI, CMS, Medicare, MassHealth) Experience in claims processing against authorization status highly preferred Experience with managed care plan benefits, Medicare and Medicaid coverage criteria requirements required Experience developing policies, procedures, and workflows preferred Experience with performance improvement projects including but not limited to establishing criteria for report queries, utilizing objective data to improve processes, and implementation of projects preferred Ensuring team performance goals are met and ensuring program staff are trained and compliant with departmental and policy requirements Educating direct reports on various levels of prior authorization interventions and recommending and supporting team actions to ensure effective resolution of authorization requests active participant in Clinical Rounds Experience in a payer setting, managed care preferred. Excellent verbal and written communication/presentation skills, and ability to interact with all levels of staff and leadership Demonstrated leadership and team management skills. Ability to analyze, synthesize and effectively communicate information. 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.
The Manager, Prior Authorization RN manages all staffing and activities related to prior authorization which includes but is not limited to preservice, concurrent and retrospective reviews for medical necessity or benefit review. Along with other members of the medical management leadership team, the Manager is responsible for the quality and cost effectiveness of care provided to Fallon Health (FH) members. Specific responsibilities include: Ensures that accurate, timely information for all members requiring prior authorization is captured and disseminated to appropriate staff daily. Utilizes approved FH criteria in addition to InterQual, MassHealth and Medicare guidelines when completing outpatient authorization reviews such as Home Health, DME, genetics, ambulatory surgical procedures. Ensures that appropriate, timely turnaround times are met. Creates and disseminates all required utilization reports on a daily, monthly, quarterly and annual basis. Maintains appropriate staffing levels for the PA Team. Responsible for the ongoing development and implementation of new strategies, processes, policies and procedures related to the PA/UM program ensuring compliance with governmental, accrediting agency and health plan requirements. Meets departmental utilization and budgetary goals on a monthly, quarterly and annual basis. Supports plan accreditation efforts as they related to Prior Authorization UM. Oversees all activities of the Supervisor, PA RN and their direct and indirect reports. Functions independently and generally establishes own work plan and priorities, using and / or modifying established procedures, to assure timely completion of assigned work in conformance with established departmental policies and standards; problems lacking clear precedent are usually reviewed with the Director, UM and PA prior to taking action. Qualifications
Education: Graduate from an accredited school of nursing or Bachelor's (or advanced) degree in nursing. Experience in a managed care or healthcare setting preferred. License/Certifications: Active, unrestricted license as a Registered Nurse In Massachusetts Experience: A minimum of three to five years' clinical experience as a Registered Nurse, in a clinical setting required. Minimum of three to five years' experience as a utilization nurse in a payer or facility setting highly preferred. Discharge planning experience preferred. Experience in outpatient authorization processing (including Home Health Care, DME, genetics, ambulatory surgery) highly preferred Experience in regulatory requirements in a payor or facility setting highly preferred (NCQA, DOI, CMS, Medicare, MassHealth) Experience in claims processing against authorization status highly preferred Experience with managed care plan benefits, Medicare and Medicaid coverage criteria requirements required Experience developing policies, procedures, and workflows preferred Experience with performance improvement projects including but not limited to establishing criteria for report queries, utilizing objective data to improve processes, and implementation of projects preferred Ensuring team performance goals are met and ensuring program staff are trained and compliant with departmental and policy requirements Educating direct reports on various levels of prior authorization interventions and recommending and supporting team actions to ensure effective resolution of authorization requests active participant in Clinical Rounds Experience in a payer setting, managed care preferred. Excellent verbal and written communication/presentation skills, and ability to interact with all levels of staff and leadership Demonstrated leadership and team management skills. Ability to analyze, synthesize and effectively communicate information. 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.