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. Learn more at fallonhealth.org or follow us on Facebook, Twitter and LinkedIn.
Brief Summary of Purpose:
The Utilization Management Trainer develops training curriculum and facilitates and manages staff training activities for staff. The Trainer provides regular training to all staff, as needed, as well as remedial training. The Trainer additionally understands ProAuth tool requirements for provider authorization submission; develops curriculum and facilitates training for new ProAuth users. The Trainer provides responses to ProAuth tool inquiries to ensure providers understand the authorization submission process.
ResponsibilitiesPrimary summary of purpose:
Develops training curriculum for Prior Authorization Department staff, including written, desktop reference material and electronic modules Materials must be compliant with NCQA, Medicare, Medicaid and state and federal regulations.Orients new staff, serving as preceptor and provides mentoring to new employees on an ongoing basis. Identifies training opportunities, individual and team coaching needs and reports findings to management.Maintains training curriculum and updates regularly, including best practices, as well as regulatory requirement changes and updates. Collaborates with multiple departments to ensure training is compliant and efficient.Collaborates with Quality Specialist to facilitate internal audit activities and supplemental training, as identified through audit procedures.Identifies service issues and processes that impact member satisfaction and provides input to leadership about the issues.Strong understanding of department goals and processes, including introductory database management and case triage process. Understands interdepartmental processes and relationships.Develops and maintains training program for ProAuth authorization tool utilized by providers for authorization submission. Collaborates with Network Development and Management team to train new and existing providers on ProAuth tool usage.Assists with internal and external audits, as assigned by manager.Manages special projects, as assigned by manager.
Qualifications
Education:
Bachelor’s Degree or equivalent experience in managed health care.
Experience:
2 to 4 years training experience or extensive prior authorization (PA)/utilization management (UM) process experience. Subject matter expert in prior authorization/utilization management processes and managed care regulatory requirements. Proficient in managed care regulations training methodologies. Advanced understanding of department policies and procedures for authorization processing and its connection to claims payment. Effective communication skills relating to communicating complex procedures and medical terminology. Comfortable interacting and communicating with professionals at multiple levels, both internally and externally.
Resources used in performing role:
Microsoft Office Suite, TruCare and ProAuth platform, QNXT
Fallon Health provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.
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