Prior Auth Service Coordinator

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Under the direction of the Manager of Prior Authorization, communicates with contracted and non‑contracted facilities/agencies/providers to collect pertinent prior authorization request data and disseminates information to the Authorization Coordinators. Additionally, supports the authorization process by receiving incoming faxed/mailed/emailed/etc. requests and initiates entry of service request shells into core system – Tru Care. Responsible for incoming calls from the multiple ACD lines for the UM department addressing and/or referring customer (provider/member) calls/inquiries, providing direction regarding plan policies, procedures and when applicable, benefit information.

Works in conjunction with other Fallon Health departments to assist in processing authorization information in order to facilitate the member’s medical services or the providers’ claims. Interprets and triages information to ensure appropriate action is initiated to meet regulatory bodies’ standards and to maintain the quality and timeliness of the authorization process.

• Accepts authorization service requests and notifications for FCHP members, screens for member eligibility, additional active insurance coverage and authorization history from the core system.
• Initiates entry of request(s) into core system (QNXT/Tru Care) and case management application (Tru Care) as applicable.
• Updates authorization information in QNXT because of determinations made by Authorization Coordinators, Nurse Reviewers and/or Nurse Care Specialists.
• Handles an appropriately high volume of daily auth entries into the core system (QNXT). This volume target will be communicated to the staff on a regular basis by the Manager as business needs dictate.
• Prepares completed authorization records for filing in accordance with company record retention policy.
• Assists with departmental auto‑fax process including running error reports and missing Fax # report daily as assigned.
• Generates notifications to members, facilities, and agencies according to established protocol (auto‑fax notification process and auto‑generated letter process from the core system).
• Interfaces with other FCHP departments to obtain and verify information relevant to pre‑authorization requests (e.g. contract information, benefits, etc.), including authorization details when requested for appeals.
• Distributes departmental facsimiles; checks Right Fax no less than hourly throughout the day; follows established process for determining to whom facsimiles are to be delivered; researches facsimiles inappropriately addressed by using the core system (QNXT) or by communicating with appropriate individuals for assistance; redirects/saves facsimiles as indicated to the staff and/or G drive.
• Manage applicable queues in both the core system (QNXT UM and Call Tracking) and the case management application (Tru Care).
• Enters/extends/changes approved authorizations within established parameters.

• Communicates with contracted and non‑contracted facilities/agencies/providers to collect…