Fallon Health Account & Provider Configuration Analyst - Health Plan Operations 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 the only health plan in Massachusetts to have been awarded “Excellent” Accreditation by the National Committee for Quality Assurance for its HMO, Medicare Advantage and Medicaid products. For more information, visit.

Position Overview:

The Account and Provider Configuration Analyst works within the Configuration and Support department to ensure all new and existing sponsor and provider information is entered into the QNXT system and all other related databases in a timely and accurate manner. He/She also works to ensure all Sponsor related materials are created and sent to appropriate membership and based off of the materials configures the appropriate benefits within the PCS application. He/She works to ensure that all error, data integrity and various reports are processed effectively pertaining to all system applications used.

The configuration work you are responsible for will impact the end result of our health plans as well as the quality of our claims operations, customer care operations, and cost containment & recovery operations. With a strong dedication to excellent quality of work, ensures that our members and providers have a positive experience as part of the Fallon Health network, and that we pay claims correctly and on time, avoiding fines and extra costs. When a health plan operates as expected by our members and providers leads to a great healthcare experience and the best possible outcomes.


  • Printing of routed sponsor benefit change requests out of Crystal Enterprise

  • Creation of various lines of New Business upon elected effective date within the QNXT application

  • Processing of various lines of business upon anniversary date within the QNXT application inclusive of configuration and assignment of rate codes, copay and coinsurance groups

  • Creation of Org Policy and all applicable attribute information

  • Configuration and requests of sponsor ID cards

  • Request and ordering of all benefit related documents and ensuring such is done in SLA timeframes, in turn using these documents to configure PCS benefits

  • Quality Control on all implemented data

  • Maintenance of productivity logs

  • Maintenance of all assigned fulfillment codes

  • Processing of all Termination and Reinstatement requests for various lines of business received and ensuring this information is referenced in QNXT and Avenue applications along with updating fulfillment information

  • Initial set up of rate table within QNXT Sponsor Module

  • Processing of Territory, Demographic, tiers, billing, office locations, contract entities and Probationary Period changes in applicable systems

  • Coding and Processing of Renewing “As Is” sponsor information routed from the sales team

  • Configuring benefits within the PCS application across all lines of business within SLA’s

  • Data entry of standard provider information into QNXT system and other related databases according to established departmental standards for accuracy and timeliness.

  • Determine completeness of forms prior to entry. Research any misleading or missing data fields and escalate any unresolved issues to Manager

  • Work with Provider Relations/ Contract Managers on identified discrepancies

  • Research and update all provider NPI, Medicaid or Medicare numbers as providers are enrolled into QNXT

  • Responsible for ensuring edits and call tracking cases are completed within applicable SLA on a timely basis

  • Fully support internal audits and respond timely to any resulting action plans

  • As an analyst, it is expected you will explore process improvement opportunities as well as mentor new and current team members

  • Expedite implementation delays and escalate issues to upper management as appropriate

  • Strictly observe the Fallon Health policy regarding confidentiality of member or provider information.

  • Flag all contracted providers to display or print in the directory as identified on the distribution notification forms.

  • Researching daily ID card errors

  • Ensures all Caremark member inaccuracies are resolved in a timely manner

  • Working daily Clarity Material errors

  • Working daily Data Integrity kick-outs in the QNXT system

  • Working edits pertaining to Medicare supplement contracts

  • Working 1099 issues along side the finance department to ensure accuracy of the IRS file

  • Work call tracking cases in a timely and accurate manner

  • Assisting in sales/Customer service requests for ID card/materials mailings

  • Assignment of fulfillment codes for new or updated product configurations

  • New Business and Renewal sales support contact

  • Supplying assigned code information to various departments to assist in member grievances or research

  • Requesting of Caremark Pharmacare codes

  • Partaking in miscellaneous projects at Fallon Health

  • Participate in research and testing of system application accuracy to resolve processing problems.



College Degree or equivalent experience


  • QNXT experience preferred, 3-5 years Healthcare

  • Basic analytical & quantitative skills to identify member or provider downstream impact as a result of invalid entry/configuration

  • Intermediate MS Office experience with an emphasis on MS Excel and Access skills in order to manipulate and communicate data

  • Organizational skill with the ability to effectively manage multiple projects simultaneously

Job ID 5529

# Positions 1

Category Other