LTSS Authorization Coordinator

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. 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 programs-including 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.

Brief summary of purpose:

The FH LTSS authorization process is an essential function to FH's compliance with CMS regulations, NCQA standards, other applicable regulatory requirements, and customer expectations. The LTSS Authorization Coordinator serves to administer the FH prior authorization process as outlined in the Plan Member Handbook/Evidence of Coverage, Medical Necessity Guidelines, departmental policies and procedures, and regulatory standards. The LTSS Authorization Coordinator serves as a liaison between FH members and/or provider offices and FH with their authorization management issues. Thorough research, documentation, and corrective action planning must be established for each respective case and adjudication completed in accordance with existing regulations, policies, and standards.

Primary Job Responsibilities:

Administers FH LTSS authorization processes as outlined in Member Handbook/Evidence of Coverage for NaviCare and in compliance with applicable CMS and NCQA standards and other state or federal regulatory requirements. Strictly adheres to department turn-around time standards established in accordance with regulatory standards.
• Enters, researches, investigates, and documents all authorizations from receipt to notification into QNXT and/or TruCare for NaviCare and other product lines as needed.
• Authorization management for NaviCare members, including but not limited to LTSS services- LTSS services are defined as the services used by individuals of all ages with functional limitations and chronic illnesses who need assistance to perform routine daily activities such as bathing, dressing, preparing meals, and administering medications.
• First point of contact to answer all inquiries sent to the Care Management authorization email, Including but not limited to, researching and corresponding regarding any type of authorization related questions and or issues, assisting DME vendors with invoice processing, working with Fallon Health UM to process LTSS service requests, resolving any provider related authorization issue and concern/questions and assisting Fallon Health claims unit when needed
• Manages and works the Care Management Right Fax Authorization folder and in an organized manner each business day.
• Manages and works the long-term care and short- term custodial tasks; ensuring authorizations get sent to the facilities promptly.
• Responsible for ensuring LTC and STC authorizations are coded according to member's appropriate rating category and for the timeframe outlined in the policy and procedure related to LTC authorizations.
• Collaborates closely with the LTC team to ensure consistency of authorizations in alignment with member needs and facility documented rating category accuracy.
• Applies criteria to ensure LTSS services requested meet criteria; and accurately enters authorizations into Fallon Health systems into a timely manner to ensure compliance with CMS timeframes for all appropriate Fallon Health products.
• Reviews and evaluates incoming requests for completeness and accuracy and discusses any discrepancies with the care team; teaching staff when issues are identified; and working with Care Management Leaders reporting when staff need further teaching to improve submissions.
• When processing LTSS authorization requests; screens for member eligibility and follows process when members are not eligible.
• Data enters LTSS authorization requests and sends them to LTSS RN Reviewer to complete review against Medical Necessity criteria, state, and federal guidelines.
• Supports with sending notification of authorization changes to the appropriate vendor/provider contacts when changes to authorizations are finalized in TruCare.
• Educates care management staff, vendors, and providers on authorization processes.
• Proactively investigates pending claim issues associated with authorizations and works to identify a solution and implements correction to resolve claim issues.
• Sends notification to appropriate vendor/provider contacts in cases of decreased service level or member not meeting eligibility guidelines for service Notifies members and providers of any additional instructions necessary once authorization approval has been obtained from the reviewers; answers question and provides direction and support.
• Adheres to department standards for completion of authorization turn-around time and notification.
• Answers authorization questions from members and providers, as needed.
• Communicates both by telephone and on-site, as needed, with FH providers and staff to facilitate the Pre-Authorization Process.
• Supports claims functions through authorization adjustment guidelines to assist with adjudication of claims provided for missing information.

License/Certifications:

Medical Terminology or Medical Coding helpful

Experience:

• 1-3 years professional experience in related position, preferably in health care.
• Experience in a managed care, call center setting or physician's office; knowledge of managed care and/or utilization management strategies preferred.
• Excellent writing skills with familiarity and comfort with medical terminology.
• Ability to work independently and make appropriate decisions within the realm of set business and benefit guidelines.
• Excellent interpersonal communication and critical thinking skills.
• Excellent research and documentation skills.
• Excellent writing skills.
• Computer literate, particularly in Windows based applications (Word, Excel, PowerPoint, and Access).
• Experience in EMR or other healthcare documentation systems preferred

Pay Range Disclosure:

In accordance with the Massachusetts Wage Transparency Act, the pay range for this position is $26 - $29 per hour which reflects what we reasonably and in good faith expect to pay at the time of posting. Final compensation will depend on the candidate's experience, skills, and fit with the role's responsibilities.

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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