Fallon Health Manager, Prior Authorization and Operational Compliance in Worcester, Massachusetts


About Fallon Health

Founded in 1977, Fallon Health is a leading health care services organization that supports the diverse and changing needs of those we serve. In addition to offering innovative health insurance solutions and a variety of Medicaid and Medicare products, we excel in creating unique health care programs and services that provide coordinated, integrated care for seniors and individuals with complex health needs. Fallon has consistently ranked among the nation’s top health plans, and is accredited by the National Committee for Quality Assurance for its HMO, Medicare Advantage and Medicaid products. For more information, visit fallonhealth.org.

Brief Summary of Purpose:

Manages the daily operations of the Prior Authorization Unit; responsible for developing and implementing processes that enhance the efficiency and effectiveness of the Prior Authorization Program. Involved in key FH committees which have any impact on the authorization process. Manages the operational compliance related to all functions of utilization management, in accordance with regulations and accreditation standards. Acts as the subject matter expert (SME) for the Trucare application and regulatory reports as required. Represents the Vice President, Clinical Operations, when necessary.


  • Works with appropriate Fallon Health (FH) units / departments and Physicians to automate and streamline the authorizations process through continuous monitoring and implementation of telephonic review and electronic authorization processes.

  • Works with Vice President of department to identify opportunities of improvement and/or efficiency such as codes/services that may not require authorization and bring them up to the appropriate committee for review/assessment.

  • Hires, orients, supervises and evaluates staff that functions within the Unit; establishes productivity and goals with staff and evaluates performance based on these defined; conducts staff meetings on a regular basis.

  • Evaluates staffing, operational and budget needs to ensure that the day-to-day operations of the Unit are carried out appropriately and efficiently.

  • Develops and utilizes reports to effectively manage and continuously improve the Program; utilizes reports and data to identify and document productivity, turnaround times, authorization volume and compliance with regulatory standards; provides feedback and education to staff as warranted.

  • Proactively monitors NCQA, Medicare, Medicaid, Division of Insurance to monitor compliance and identify any changes in regulations; anticipates the effects these may have on Care Services and helps create strategies to initiate and/or promote change.

  • Participates in regulatory report creation, internal and regulatory audits and accreditation process.

  • Develops audit processes to ensure authorization quality, performance and decision consistency.

  • Acts as a resource and educator for the Unit; educates staff on all regulatory changes.

  • Acts as liaison to all internal departments and provides consultation and project assistance as required.

  • Develops and conducts education / training sessions regarding the Prior Authorization Process to FH internal and external customers.

  • In collaboration with the VP of Clinical Integration and Medical Directors, assist in the administration and oversight of the inter-rater reliability program.

  • Provides regular reporting on operational compliance activities. Collaborates with other staff, departments and agencies to meet cross functional goals, overall productivity and compliance.

  • In collaboration with the VP of Clinical Integration and Medical Directors, review the outcomes of prior authorization activities to continuously refine the list of services for placement under or removal from the prior authorization program.

  • Works closely with Business Intelligence in creating reports in accordance with reporting needs for internal customers and external agencies.

  • Creates, implements and/or updates UM Policies and Procedures as necessary or required for yearly evaluation.

  • Responds to customer concerns and / or feedback and uses this information to further refine internal processes.

  • Interfaces and resolves issues with contracted and non-contracted vendors for all ancillary care (e.g., home health, DME, Infusion Therapy, Outpatient Rehab Facilities, etc.) to ensure appropriate service is delivered to Fallon Health members.

  • Attends FH committee meetings as assigned by VP of Clinical Integration or designee, such as Trucare Production meetings, Auth Automation development meetings, report development meetings with IT, Claims edit meetings, etc.

  • Assist in development and writing of required documents for Auth Automation and downstream impacted areas including but not limited to reporting and training of internal and external entities.

  • Be the contact person for internal customers with Auth related issues, including but not limited to Sales, Claims, Provider Relations, Communications, Appeals and Case Management.

  • Strictly observes the HIPPA regulations and the FH policy regarding confidentiality of member information.

  • Performs other duties or responsibilities as assigned by the VP of Clinical Operations or designee based on the needs of the business.


Education :

Bachelor’s degree or higher, preferably in focus on healthcare administration, communications or business.

Minimum of five years of healthcare setting experience, either in a provider office, facility or managed care payer environment; minimum of 5 years managerial experience.

QNXT, TruCare, Business Objects

Job ID 5423

# Positions 1

Category Care Coordination