Job Description
Qualifications
Bachelor’s Degree or equivalent experience in managed health care
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
Microsoft Office Suite, TruCare and ProAuth platform, QNXT
Responsibilities
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
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
Job description
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 1+77 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, ****** 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.
Responsibilities
Primary 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.
Education
Qualifications
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, ****** orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.
#P02
Bachelor’s Degree or equivalent experience in managed health care
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
Microsoft Office Suite, TruCare and ProAuth platform, QNXT
Responsibilities
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
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
Job description
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 1+77 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, ****** 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.
Responsibilities
Primary 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.
Education
Qualifications
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, ****** orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.
#P02
💡 Quick Summary
Seeking a career-building opportunity? The Trainer | Utilization Management Team position is now open for candidates interested in the Health Jobs sector. This role in Worcester offers a professional environment and growth potential.
Requirement Snapshot: Candidates should possess basic communication skills, a proactive attitude, and the ability to work in a team. Experience in Health Jobs is a plus.
