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Fallon Health Business Process Coordinator - Growing Health Care Org 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 .


The Fallon Health authorization process is an essential function to Fallon Health’s compliance with CMS regulations, NCQA standards, regulatory requirements, and customer expectations. The Business Process Coordinator II supports these functions through authorization discrepancy and reconciliation quality analysis. This process assures the end result of processing all services in accordance with member’s rights as outlined in the Member Handbook/Evidence of Coverage, authorization policies, procedures and benefit design across all of Care Services programs across all product lines (including SCO, PACE, Commercial, Medicare, Medicaid and Dual Eligible products, etc.). Utilizing their extensive knowledge of regulatory guidelines, UM protocols, claims processing guidelines and benefit design and system configuration, the Business Process Coordinator II is responsible to support the review and response relating to authorization and claim discrepancies reported within the TruCare and QNXT systems.

The Business Process Coordinator is responsible for:

  • Researching and reconciling authorization and claim discrepancies

  • Identifying trends and opportunities for reeducation and process improvement related to the initial authorization data entry and claims processing

  • Ensuring all Care Services business requirements are accurately followed

  • Making necessary modifications to authorizations; creating new authorizations as appropriate to adjudicate claims to resolve discrepancies

  • Assisting in reconciliation of authorization template configuration as it supports claims adjudication

  • Assisting in designing, developing, and maintaining TruCare authorization entry education materials for Care Services Division

The Business Process Coordinator II is the link between the authorization / claims process, assuring that the member, provider and Fallon Health complete an effective circle of servicing the member from request through rendering payment by driving change through collaboration with all Care Services departments to achieve quality data entry of authorizations on a consistent basis.


Authorization & Claims Edit Review and Resolution:

  • Performs research of pending claims stemming from authorization match discrepancies reported in the QNXT Claims Workflow Module

  • Modifies authorizations based upon established protocols and recommendations provided by clinical staff.

  • Presents authorization cases to medical director or clinical nurse reviewer when necessary

  • Ensures all authorization and claim discrepancies are reviewed, responded to and reported in a timely manner

  • Responsible to research and clear the Pended 600 Edits QNXT Call Tacking Queue on a daily basis

  • Collaborates with UM and Pharmacy subject matter experts regarding pending authorization based on discrepancies

  • Ensures the Pended Claims Report is reviewed and maintained on a daily basis, and claims are reviewed and released within established timeframes

  • Researches, documents, and communicates procedure code discrepancies configured in the UM Service Groups to appropriate parties, in consultation with the Lead Business Process Specialists

  • Collaborates with Care Services, Claims, Provider Relations and Business Solutions Services, Operation Services, and others, including internal work groups, to identify and communicate changes to Claims Workflow functionality, in collaboration with the Lead Business Process Specialist

QNXT Authorization Education:

  • Identify and communicate reeducation and improvement opportunities in collaboration with the Lead Business Process Specialist

  • Provide education and/or retraining to existing staff as needed, or upon configuration implementation relating to authorization templates and/or service groups, in collaboration with the Lead Business Process Specialist

  • Provide TruCare authorization educational sessions to all new Care Services employees, in collaboration with the Lead Business Process Specialist

  • Design and develop customized departmental education, in collaboration with the Lead Business Process Specialist

  • Special projects as assigned by management


Education, Licenses, certification and experience requirements:

Education: College degree (B.S. or B.A.) or equivalent experience

License: N/A

Certification: Medical Terminology or Medical Coding


Minimum 3-5 years of experience in a managed care organization.

Advanced understanding of managed care practices, including claims processing, billing and coding practices, and utilization management related to authorization entry and coding proctices helpful.

Preivous experience with core processing systems, such as QNXT and/or TruCare.


  • Analytical Ability

  • Adaptability

  • Problem Solving

  • Fosters Open Communication

  • Effective Communication

  • Approachability

  • Creativity

Additional Performance Requirements:

  • Requires advanced understanding of policies and procedures for UM, Payment Policies, and Regulatory guidelines (i.e. NCQA, CMS) as it pertains to claims processing and UM functions.

  • Requires an advanced understanding of Claims processing and UM protocols, as well as the impact of member enrollment and provider configuration updates

  • Requires a working familiarity and understanding of managed care, such utilization management, authorization management, and pharmacy management

  • Strong analytical background, including root cause analysis

  • Ability to effectively communicate complex findings, information, and concepts

  • Ability to interact with a wide range of professional levels

  • Proficient in Microsoft Office Suite (e.g., Excel, Access, Word, PowerPoint)

Job ID 5698

# Positions 1

Category Utilization Management