Director, Utilization Management & Prior Authorization

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. 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.

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Brief summary of purpose:

With the general direction from the VP Sr. Medical Director Clinical Management and SVP/Chief Medical Officer will provide strategic leadership and oversight responsibility for the clinical and operational utilization management activities for all inpatient and outpatient care, and staff across all product lines.

Utilization Management:

• Oversees all administrative, operational and clinical functions related to outpatient and inpatient, utilization management operations, including but not limited to prior authorization, concurrent review and discharge planning.
• Ensures that members get the appropriate care that is medically necessary and meets the benefit coverage criteria.
• Ensures that all reviews meet the appropriate regulatory and accreditation requirements including turnaround times and communication.
• Ensures program compliance with all federal regulatory and state mandates, Division of Insurance, National Committee for Quality Assurance standards, Centers for Medicare and Medicaid guidance and requirements, Mass Health (Medicaid contractual agreements).
• Responsible for hiring appropriate non-physician clinical and non-clinical personnel to review medical cases and determine if requests for services meet medical necessities and criteria for coverage.
• Oversight of UM by delegated organizations and ensure regulatory and accreditation compliance,
• Monitors and analysis of operational and outcome data related to all utilization management activities.
• Recommends and implements innovative process improvements for the prior authorization and utilization management processes
• Develops and implements the Utilization Management Program Description and annually evaluate the effectiveness of the program.
• Represents the UM Department in Program Audits across all LOBs, including information gathering, research, presenting, and development of Corrective Action Plans (if applicable)
• Key Contact for RFP responses related to UM Functions and department organization structure/staffing.
• Works with VP/Medical Director to identify and prioritize the cost of care opportunities related to Utilization Management.
• Works with VP/ Medical Director to set agenda related to UM and represent the plan at clinical joint operating committees to support collaborative Fallon/provider group relationship.
• Manages data, predictive analytics to improve efficiency of prior authorization and utilization management
• Works with and represents Care Services for utilization management on the different product line task forces at Fallon.
• Serves as SME and Point of Contact for internal committees including but not limited to Delegation Oversight Committee (DOC), Payment Policy, Mental Health Parity, Medical Directors monthly meeting, and Tru Care Insights/upgrade meetings.
• Represents the Vice President and Senior Medical Director of Clinical Management at internal and external senior level meetings.
• Budget creation and management of annual budget.

Clinical Integration Support:

• Provides UM expertise to Clinical Integration leadership to ensure seamless integrated member care within Care…