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Fallon Health Claims Administration Manager - Hybrid Position 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 www.fallonhealth.org .

Brief Summary of Purpose :

The Claims Administration Manager will be responsible for the overall operational leadership of the claims organization. This role will also play an active role in the establishment of the organization, working closely with project teams responsible for the development and continued enhancement of the claims processing technical platform.


Job Responsibilities:

  • Propose initiatives that support the strategic objectives of the larger organization, identifying short and longer-term requirements.

  • Conduct/Oversee studies or analysis to determine feasibility and costs of initiatives.

  • Determine long-term resources (systems, skills needed, capacity planning, etc.) to meet future business needs.

  • Participate in cost/benefit analysis of operational changes in support of future business requirements.

  • Regularly track group/departmental costs, ensuring these are managed within budget. Employ cost containment measures while retaining quality and efficient operations and a productive, healthy work environment. Anticipate expenses and identify potential budgetary concerns to Senior Director of Claims and Configuration.

  • Regularly analyze and report on the productivity and effectiveness of the operations in comparison to established performance metrics. Identify areas of improvement and recommend resolution.

  • Work cross-functionally to ensure operations and changes are well integrated.

  • Proactively seek feedback from other groups on the impact and effectiveness of current and changes to operations.

  • Implement, manage, and refine business processes required to deliver expected business results.

  • Implement short-term staffing plans to ensure anticipated operational requirements are met. Monitor the workload and adjust staff assignments accordingly.

  • Ensure team has appropriate resources and highlights areas of need to Senior Director for resolution.

  • Ensure the timely and accurate exchange of information/data with relevant stakeholders of the operation.

  • Monitor the work environment and the business operation. Address concerns that may affect the morale and/or operational effectiveness of the group.

  • Oversee managers and their role in developing and managing staff.

  • Ensure objectives defined across a broader group are integrated and supportive where necessary.

  • Define roles and accountabilities for staff, within the group and in the context of the broader process/operation in support of cross-functional efforts.

  • Hire for, develop, and recognize the experience and knowledge/skills/abilities required for a successful team.

  • Provide for the orientation and welcome of new staff.

  • Define performance expectations and goals for staff.

  • Train and mentor staff on the application of policy and procedures, use of supporting systems/applications, appropriate soft skills: time management, etc.

  • Monitor work of individual staff for efficiency, effectiveness, and quality. Provide ongoing constructive feedback and guidance to staff.

  • Evaluate staff on achievement of goals and deliverables and assessment of competencies. Help staff progress in their careers to the benefit of the department and broader organization. Manage the resolution of performance issues in consultation with Human Resources as appropriate.

  • Proactively communicate with other departments to ensure cross-functional concerns are identified and effectively addressed.

  • Establish and maintain an open communication channel with staff.

  • Monitor effectiveness of communication with other groups (internal and external). Collaborates with Senior Director to implement changes as necessary to ensure an open, productive exchange of information.

  • Represent the department as requested.

  • Keep abreast of relevant regulatory (pending and potential) updates. Identify and plan for potential impact to operations.

  • Ensure relevant changes to operations and/or contractual requirements can be supported.

  • Ensure operational compliance with all relevant regulatory agencies.

  • Ensure operations meet vendor/customer contractual requirements.

  • Keep abreast of changes in requirements.

  • Proactively identify areas of concern or exceptions and promptly notify stakeholders

  • Serve as a subject matter expert and provide peer support in a mentoring or collaborative capacity in the office environment, whether it be training or answering of questions, as deemed appropriate by management.



Bachelor's degree in business or other applicable field. Master’s degree in business or another applicable field preferred.




  • Minimum of five (5) years of claims and health care administration and/or managed care experience with managerial experience.

  • Strong claims knowledge of health insurance industry with all product lines (Medicare, Medicaid, Commercial, ASO, PPO, PACE, Duals, FHW, etc.)

  • Extensive knowledge of claims policies and procedures, including regulatory requirements and industry standards from AMA, CMS and CCI Edits.

  • Strong Communication and Presentation skills.

  • Strong Analytical Ability

  • Extensive knowledge of federal and state regulations, legislation and laws, auditing reports and system functions; comparing functions with established standards.

  • Ability to and experience in forecasting.

  • Ability to perform root causal analysis and impact assessments with the goal of mitigation and/or process improvements.

Fallon Health Vaccination Requirements:

To protect the health and safety of our workforce, members and communities we serve, Fallon Health now requires all employees to disclose COVID-19 vaccination status. As of 2/1/2022 all roles not designated as “Remote” require full COVID-19 vaccination and Fallon Health will obtain the necessary information from candidates prior to employment to ensure compliance. Failure to meet the vaccination requirement may result in rescission of an employment offer or termination of employment.

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.


Location US-MA-Worcester

Posted Date 2 months ago (8/10/2022 3:19 PM)

Job ID 6987

# Positions 1

Category Claims Administration