LTSS Vendor Liaison

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, we deliver equitable, high-quality coordinated care and are continually rated among the nation's top health plans for member experience, service, and clinical quality.

Fallon Health's NaviCare is a program for people age 65 and older, who live in our service area, and who have MassHealth Standard, and may have Medicare. It combines MassHealth (Medicaid) and Medicare benefits, including prescription drug coverage. At Fallon Health, 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- in the region.

Brief summary of purpose:

The Clinical Integration LTSS Vendor Liaison is an integral part of Fallon Health's care coordination and care management and improves access to quality of care for Fallon members. The Fallon Health authorization process is an essential function of Fallon Health's compliance with CMS regulations, NCQA standards, other applicable regulatory requirements and meeting member/ vendor expectations. The Clinical Integration LTSS Vendor Liaison administrates the Fallon Health prior authorization process according to departmental policies and procedures and regulatory standards and actively partners with the Clinical Integration staff and contracted vendors to communicate at all times, what is occurring with the member and their status.

Authorization management for all of Fallon Health product lines including but not limited to LTSS services- LTSS services are defined as the services used by individuals of all ages with functional limitations and chronic illnesses who need assistance to perform routine daily activities such as bathing, dressing, preparing meals, and administering medications - Fallon Health contracts with vendors/providers to administer and provide these services and programs

First point of contact to Fallon Health contracted Long Term Service and Support (LTSS) vendors whenever authorization questions/needs arise, responding timely to LTSS vendor questions in a positive proactive customer service effective way in order to build partnerships with LTSS vendors/providers

First point of contact to resolve Personal Care Attendant (PCA) issues with the Personal Care Management (PCM) Agencies and Fiscal Intermediaries (FIs) and works all questions and issues that come into the Clinical Integration email address mailbox entitled "Navicare PCA Mailbox" at all times ensuring timely resolution of issues and enhancing partnerships with PCM Agencies and Fiscal Intermediaries

First point of contact to answer all inquiries sent to the Clinical Integration authorization email. Including but not limited to researching and corresponding regarding any type of authorization related questions and or issues, assisting Durable Medical Equipment (DME) vendors with invoice processing, working with Fallon Health UM to process LTSS service requests, resolving any provider related authorization issue and or concern/questions and assisting Fallon Health claims unit when needed

Applies criteria to ensure LTSS services requested meet criteria; and accurately enters authorizations into Fallon Health systems in a timely manner to ensure compliance with CMS timeframes for all appropriate Fallon Health products - escalates requests to Medical Directors when criteria is not met and medical necessity determination needs to be made by the Medical Director

Independently performs research to ensure resolution of identified concern and works with Manager to identify trends or training needs

Manages and works the Clinical Integration Right Fax Authorization folder and in an organized manner each business day

Manages and works the Long term care and short term custodial tasks sent by the Navigator, enters into TruCare and ensures authorizations are sent to the long term care facilities promptly

Reviews and evaluates incoming requests for completeness and accuracy and discusses any discrepancies with the Clinical Integration Care Team; teaching staff when issues are identified; and working with Clinical Integration Leaders reporting when staff need further teaching to improve submissions

When processing any LTSS authorization request; screens for member eligibility and follows process when members are not eligible

Data enters LTSS authorization requests when the referral/ request meets the eligibility guidelines provided on the Medicaid Services Non-Medical Services Request Form as generated and submitted by the Care Team

Sends notification of authorization changes to the appropriate vendor/provider contacts when changes to authorizations are finalized in TruCare

Sends notification to appropriate vendor/provider contacts in cases of decreased service level or member not meeting eligibility guidelines for services

Educates Clinical Integration staff, vendors and providers on authorization processes

Proactively investigates pended claim issues associated with authorizations and works to identify a solution and implements correction to resolve claim issues

Works collaboratively and ensures communication with Clinical Integration Care Teams and LTSS vendors/providers to ensure the member care plans support their needs

Performs other responsibilities as assigned by the Manager/designee

Supports department colleagues, covering and assuming changes in assignment as assigned by Manager/designee

May mentor and train staff on processes associated with job function and role

Education:

Minimum of high school diploma required; College degree preferred.

License/Certifications:

Medical Terminology or Medical Coding knowledge required

Experience:

* 2+ years job experience in a related field, preferably in healthcare
* Experience working with administration of Fallon Health prior authorization process preferred

Performance Requirements including but not limited to:

* Excellent organizational skills and ability to multi-task
* Ability to work independently and make appropriate decisions within the realm of set business and benefit guidelines
* Appreciation and adherence to policy and process requirements
* Independent learning skills and success with various learning methodologies including but not limited to: self-study, mentoring, classroom, and group education
* Knowledgeable about insurance regulatory and accreditation requirements
* Knowledgeable on the administration of Fallon Health authorization process and compliance with applicable CMS and NCQA standards and other state or federal regulatory requirements
* Strictly adheres to department turnaround time standards established in accordance with regulatory standards
* Knowledgeable on the coverage criteria, appeal rights and processes and the authorization request process details

Competencies:
* Demonstrates commitment to the Fallon Health Mission, Values, and Vision
* Specific competencies essential to this position:

Problem Solving

Asks good questions
Critical thinking skills, looks beyond the obvious

Adaptability

Handles day to day work challenges confidently
Willing and able to adjust to multiple demands, shifting priorities, ambiguity, and rapid change
Demonstrates flexibility

Written Communication

Is able to write clearly and succinctly in a variety of communication settings and styles

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.