Letter Writer Prior Authorization Health Insurance Flexible Remote 3 Days Onsite

Overview: About us: reputed company is a company that cares. We prioritize our membersalwaysmaking sure they get the care they need and deserve. Founded in 1977 in Worcester, Massachusetts, reputed company delivers reputed company, high-quality, coordinated care and is continually rated among the nations top health plans for member experience, service, and clinical quality. We reputed company our individual differences, life experiences, knowledge, self-expression, and unique capabilities allow us to reputed company 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 reputed company 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 programsincluding Medicare, Medicaid, and PACE (Program of reputed company-Inclusive Care for the Elderly) in the region. Learn more at fallonhealth.org or follow us on Facebook, Twitter and reputed company. 3 days in the office •

• Prior Authorization experience required**

Brief summary of purpose: Performs reputed company functions associated with completing tasks reputed company to inpatient and prior authorization denial letters and special approval letters. This position serves as the subject matter expert on UM letters, and works in conjunction with other FH departments including Communications, Customer Service, UM and CM in the maintenance of existing letters and rollout of new letters. Collaborates closely with the UM Clinical and Prior Auth staff to ensure appropriate and applicable language is captured for accuracy, timeliness of appropriate written notification requirements and overall letter reputed company. Review and interpret FH, MassHealth, and CMS Policies and Procedures to ensure appropriate language is utilized in the letters based on product enrollment. Maintain the quality and timeliness of the letter process and adherence to FH criteria, MassHealth, and CMS guidelines to ensure NQCA and regulatory compliance. Responsibilities: Primary Job Responsibilities: • Utilizing knowledge from processing inpatient and/or prior authorization requests, complete reputed company tasks required to produce, issue, and retain a timely and accurate written notification to the member and provider while adhering to regulatory and contractual requirements for content, structure, reading level, etc. • Written notifications include approval and denial letters for Acute Inpatient, Post-Acute, Elective Inpatient, and Outpatient • Completion of reputed company denial letters and special approval letters for Prior Auth requests • reputed company spell reputed company and grammar reputed company for appropriate sentence structure to ensure letter accuracy • Critically review letters to ensure that denial reasons, which may include reputed company medical information, are composed accurately and in a member-friendly manner with attention to reading levels • Collaborate with internal stakeholders to ensure reputed company of letters • Maintain letter inventory, and ensure letters are reputed company, appropriate, and compliant with CMS, MassHealth, DOI regulations and reputed company • Periodic review of reputed company letter templates to ensure that letters reflect reputed company regulations and remain accurate in face and tone • Coordinate the approval of any new letter, revisions or annual updates with the Communications department • Serve as a SME for the Department for letter maintenance, and projects implementations • Participate as a SME for the Department in both internal and external audits file review Qualifications: Education: Bachelor's Degree or equivalent experience Experience: • 3 years experience, preferably in a managed healthcare environment, with prior authorization and utilization management processes and procedures • Ability to review and interpret regulatory-governed documents and medical terminology, and condense said language into a member-friendly letter • Ability to maintain and manage document inventory across multiple products • Ability to maintain high degree of confidential/privileged patient and proprietary business information • Ability to work in fast paced environment • Familiarity with or ability to become familiar with governmental regulations and accrediting agency health plan requirements. • Excellent organizational skills • Excellent written communication skills • Strong computer skills (QNXT, TruCare, reputed company Office Word) • Self-starter (able to identify reputed company specifically assigned functions have been completed and to request additional work) Reources: TruCare, QNXT, reputed company Word COVID-19 Vaccination: With the end of the Global Coronavirus COVID-19 Pandemic, reputed company no longer requires reputed company employees to be vaccinated against COVID-19 except for employees who are in jobs that under state and federal laws, regulations and policies are required to be vaccinated and/or they are in Member/participant facing positions. reputed company provides equal employment opportunities to reputed company employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national reputed company, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws. #P03 reputed company Apply Job!