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Role Description

This is a 3 months temporary contract position for a Prior Authorization RN.

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. The PA Nurse is responsible for assuring the receipt of high quality, cost efficient medical outcomes for enrollees. This role works with Medical Directors, Authorization Coordinators, and Service Coordinators to perform pre-service, concurrent, and retrospective reviews for outpatient services such as elective procedures, home health care, DME, nutrition, and genetic testing utilizing established state, federal, and internally developed benefit and clinical coverage criteria against FH policies and protocols. Medical necessity determinations are reviewed with the holistic picture of the member in mind, which requires exceptional attention to detail, proficiency in applying correct criteria, and collaboration with internal and external partners.

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.
• Refer cases to medical review according to policy and procedure.
• Document clinical, functional, psychosocial information in the Core System as well as communications regarding the members’ care.
• Keep records and submit reports as assigned by the Manager.
• Refer high-risk cases to the appropriate FH internal teams (ie: Outpatient Case Management, NaviCare, ACO) and/or other community services according to department protocol.
• Collaborate with attending physicians and health care professionals regarding appropriate utilization of medical services.
• Complete level of care/service request reviews strictly adhering to regulatory turnaround time guidelines such as, but not limited to, CMS, NCQA, and the DOI.
• Identify utilization issues unique to their team assignment and identify strategies to address/resolve these issues.
• Issue regulatory and other letters according to the department policies and procedures.
• Keep electronic copies of all denial letters and related documents in the Fallon Health core application and/or the organization’s security accessed drive(s).
• Act as a liaison between Providers, vendors, facilities, members/families, and Fallon Health internal departments. Clarify policies/procedures and member benefits as needed. Authorize services, coordinate care, and ensure timeliness and coordination of healthcare services, in compliance with department and regulatory standards, seeking supplemental services when appropriate or when needed.
• Work with Fallon Health providers/support staff and/or members to facilitate cost-effective, quality care.
• Request and obtain relevant clinical information from medical care providers as needed for the clinical review process.
• Conduct 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, against appropriate criteria/guidelines to determine medical necessity, benefit eligibility, and network contract status.
• Refer all cases that do not meet medical necessity, benefit eligibility, and network contract status criteria to a physician reviewer for consideration, ensuring the timely review of the referred case.
• Incrementally monitor the effectiveness of established plans of care with defined, measurable goals and objectives and cost-benefit documentation as applicable and modify the care plan when applicable.
• Streamline 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.
• Analyze and apply CMS always INPT and SDS CPT codes during PA clinical reviews when a surgical procedure is requested as IP LOC.
• Collaborate 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.
• Create contingency plans for each step of the process to anticipate treatment and service complications, while ensuring that the member attains pre-determined outcomes.
• Review physician reviewers’ determinations for appropriateness and completeness.
• Communicate determinations to providers and members telephonically and in writing, adhering to corporate/department policy and regulatory guidelines.
• Check voicemail at regular intervals throughout the day and return calls/messages within the same day of receipt.
• Strictly observe the Fallon Health policies regarding confidentiality of member information, documentation standards, meeting any education requirements, and perform other responsibilities as assigned by department management team.
• Participate in weekly medical rounds with the leadership team, Medical Directors, and various Fallon Health departments to discuss patient issues and/or concerns. Organize and present complex medical cases in a clear and concise oral and written manner.
• Ensure ad hoc contracts are in place for non-contracted services working in conjunction with FH Network Development team.

Qualifications

• Graduate from an accredited school of nursing, Associate’s Degree, Bachelors Degree, or advanced degree in nursing required.
• Active and unrestricted licensure as a Registered Nurse in Massachusetts.
• 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.
• Relevant experience may include, but not be limited to experience processing authorizations for services such as:
• 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)

Company Description

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.