Fallon Health
Prior Authorization, RN - Hybrid Remote
Location: US-MA-Worcester
Overview
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. Brief summary of purpose: The PA Nurse uses a multidisciplinary approach to review service requests (prior-authorizations), focusing on selected complex medical and psychosocial needs of FH members and their families. Responsibilities
Primary Job Responsibilities Obtain clinical, functional, and psychosocial information from the medical records on site, through remote electronic access, telephonically or by fax in a collaborative effort with other health care professionals, member and/or family Refers cases to medical review according to policy and procedure Documents clinical, functional, psychosocial information in the Core System as well as communications regarding the members' care Keeps records and submits reports as assigned by the Manager Refers high-risk cases to the appropriate FH internal teams and/or other community services according to department protocol Collaborates with attending physicians and health care professionals regarding appropriate utilization of medical services Completes level of care/service request reviews strictly adhering to regulatory turnaround time guidelines Identifies utilization issues unique to their team assignment and identifies strategies to address/resolve these issues Issues regulatory and other letters according to the department policies and procedures Acts as a liaison between Providers, vendors, facilities, members/families, and Fallon Health internal departments Works with Fallon Health providers/support staff and/or members to facilitate cost-effective, quality care Requests and obtains relevant clinical information from medical care providers as needed for the clinical review process Conducts pre-authorization and concurrent clinical reviews requests for services such as DME, elective procedures, Home Health Care, Out of network specialty care, transportation and genetics Refers all cases that do not meet medical necessity, benefit eligibility, and network contract status criteria to a physician reviewer for consideration Incrementally monitors the effectiveness of established plans of care with defined, measurable goals and objectives and cost-benefit documentation as applicable Streamlines the focus of the member's healthcare needs utilizing the most optimal treatment approach, promoting timely provision of care, enhancing quality of life, and promoting cost-effectiveness of care Analyzes and applies CMS always INPT and SDS CPT codes during PA clinical reviews when a surgical procedure is requested as IP LOC Collaborates with Fallon Health departments to ensure services/items needed to facilitate discharge from a post-acute or hospital setting do not delay discharge Collaborate with external providers on alternative coverage options when services requested do not meet medical necessity, benefit eligibility, and network contract status criteria Creates contingency plans for each step of the process to anticipate treatment and service complications, while ensuring that the member attains pre-determined outcomes Reviews physician reviewers' determinations for appropriateness and completeness Communicates determinations to providers and members telephonically and in writing, adhering to corporate/department policy and regulatory guidelines Will check voicemail at regular intervals throughout the day and returns calls/messages within the same day of receipt Strictly observes the Fallon Health policies regarding confidentiality of member information, documentation standards, meeting any education requirements, and performs other responsibilities as assigned by department management team Participates in weekly medical rounds with the leadership team, Medical Directors, and various Fallon Health departments to discuss patient issues and/or concerns Ensures ad hoc contracts are in place for non-contracted services working in conjunction with FH Network Development team Qualifications
Education Graduate from an accredited school of nursing, Associate's Degree, Bachelors Degree, or advanced degree in nursing required License/Certifications Active and unrestricted licensure 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 2 years' experience as a Utilization Management/Prior Authorization nurse in a managed care payer preferred One year experience as a case manager in a payer or facility setting highly preferred Relevant experience may include but not be limited to experience working directly in the field of Home Health Care, Ambulatory Provider Setting, Rehabilitation Nursing Setting, Acute Hospital Setting Outpatient authorization requests such as: Home Health Care DME Ambulatory Procedures Genetic Testing Pharmacy Nutritional supplies Inpatient authorization requests such as: Acute Hospital Level of Care Post-Acute level of care reviews (SNF, Acute Rehab, Long Term Acute Care) 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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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. Brief summary of purpose: The PA Nurse uses a multidisciplinary approach to review service requests (prior-authorizations), focusing on selected complex medical and psychosocial needs of FH members and their families. Responsibilities
Primary Job Responsibilities Obtain clinical, functional, and psychosocial information from the medical records on site, through remote electronic access, telephonically or by fax in a collaborative effort with other health care professionals, member and/or family Refers cases to medical review according to policy and procedure Documents clinical, functional, psychosocial information in the Core System as well as communications regarding the members' care Keeps records and submits reports as assigned by the Manager Refers high-risk cases to the appropriate FH internal teams and/or other community services according to department protocol Collaborates with attending physicians and health care professionals regarding appropriate utilization of medical services Completes level of care/service request reviews strictly adhering to regulatory turnaround time guidelines Identifies utilization issues unique to their team assignment and identifies strategies to address/resolve these issues Issues regulatory and other letters according to the department policies and procedures Acts as a liaison between Providers, vendors, facilities, members/families, and Fallon Health internal departments Works with Fallon Health providers/support staff and/or members to facilitate cost-effective, quality care Requests and obtains relevant clinical information from medical care providers as needed for the clinical review process Conducts pre-authorization and concurrent clinical reviews requests for services such as DME, elective procedures, Home Health Care, Out of network specialty care, transportation and genetics Refers all cases that do not meet medical necessity, benefit eligibility, and network contract status criteria to a physician reviewer for consideration Incrementally monitors the effectiveness of established plans of care with defined, measurable goals and objectives and cost-benefit documentation as applicable Streamlines the focus of the member's healthcare needs utilizing the most optimal treatment approach, promoting timely provision of care, enhancing quality of life, and promoting cost-effectiveness of care Analyzes and applies CMS always INPT and SDS CPT codes during PA clinical reviews when a surgical procedure is requested as IP LOC Collaborates with Fallon Health departments to ensure services/items needed to facilitate discharge from a post-acute or hospital setting do not delay discharge Collaborate with external providers on alternative coverage options when services requested do not meet medical necessity, benefit eligibility, and network contract status criteria Creates contingency plans for each step of the process to anticipate treatment and service complications, while ensuring that the member attains pre-determined outcomes Reviews physician reviewers' determinations for appropriateness and completeness Communicates determinations to providers and members telephonically and in writing, adhering to corporate/department policy and regulatory guidelines Will check voicemail at regular intervals throughout the day and returns calls/messages within the same day of receipt Strictly observes the Fallon Health policies regarding confidentiality of member information, documentation standards, meeting any education requirements, and performs other responsibilities as assigned by department management team Participates in weekly medical rounds with the leadership team, Medical Directors, and various Fallon Health departments to discuss patient issues and/or concerns Ensures ad hoc contracts are in place for non-contracted services working in conjunction with FH Network Development team Qualifications
Education Graduate from an accredited school of nursing, Associate's Degree, Bachelors Degree, or advanced degree in nursing required License/Certifications Active and unrestricted licensure 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 2 years' experience as a Utilization Management/Prior Authorization nurse in a managed care payer preferred One year experience as a case manager in a payer or facility setting highly preferred Relevant experience may include but not be limited to experience working directly in the field of Home Health Care, Ambulatory Provider Setting, Rehabilitation Nursing Setting, Acute Hospital Setting Outpatient authorization requests such as: Home Health Care DME Ambulatory Procedures Genetic Testing Pharmacy Nutritional supplies Inpatient authorization requests such as: Acute Hospital Level of Care Post-Acute level of care reviews (SNF, Acute Rehab, Long Term Acute Care) 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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