Temporary Prior Authorization RN - Hybrid Remote

Overview

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

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—in the region.

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. The PA Nurse is responsible for ensuring 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.

• 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, Navi Care, 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 the team assignment and identify strategies to address/resolve these issues
• Issue regulatory and other letters according to 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 secure 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 health‑care services in compliance with department and regulatory standards; seek supplemental services when appropriate or 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 review 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…