Fallon Health Claims Examiner Representative - Health Insurance 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 accredited by the National Committee for Quality Assurance for its HMO, Medicare Advantage and Medicaid products. For more information, visit.
The Claims Examiner should have thorough claim processing knowledge at a complex level. Knowledge of all Claims Processor competencies plus added responsibility for resolving pended claims. Thorough understanding of authorizations, benefits, contracts, enrollment and fee schedules. Ensures member and provider satisfaction by providing appropriate and timely processing of involved cases and claims (multi-step resolution). Monitors and resolves high volume of claims for all lines of business, as well as claims for performance guarantee groups and high dollar claims, to minimize late payment interest penalties and ensure compliance with established guidelines. Must be able to work on tasks both independently and as part of a team.
Meets or exceeds all department standards: productivity; quality; and attendance.
Responsible for resolving a high volume of claims edits for all lines of business.
Thorough knowledge of Fallon Health policies and procedures.
Thorough understanding of authorizations, benefits, contracts, enrollment and fee schedules.
Price claims using external vendor processing systems and manually apply rates in the core system.
Resolution of complex and high dollar claims.
Ensures accuracy and timeliness of claims processing to minimize late payment interest penalties and ensure compliance with established guidelines.
Evaluation and resolution of Customer Service cases related to pended claims.
Demonstrate solid judgment and discretion working with confidential information.
Comply with all department and company guidelines including all applicable laws and regulations.
Demonstrates ability to perform independently in conformance with written instructions, established timeframes, and pre-determined priorities.
Seeks intermittent assistance from Team Subject Matter Experts (SMEs), the Trainer and Claims Manager to ensure accuracy of adjudicating claims and to develop individual skills and grow professionally.
Work with teams inside and outside the department, and external customers as needed.
The above is intended to describe the general content of the requirments for the performance of the job. It is not to be construed as an exhaustive statement of duties, responsibilities or requirements
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.
High school diploma, college degree preferred. Medical billing and coding or equivalent experience preferred.
Minimum of 2 years health care industry experience or equivalent
Solid working knowledge of CPT, ICD-10, HCPCS coding guidelines and medical terminology preferred.
Demonstrated ability to enter and process medium complexity claims efficiently and in a quality manner.
Solid working knowledge of claim processing from all perspectives (submissions, processing, dependencies)
MS Office and general PC skills.
Specific competencies essential to this position:
Analytical ability – Gathers relevant information systematically. Considers a full range of issues or factors. Grasps complexities and perceives relatioinships among problems or issues. Seeks input from others as appropriate.
Problem solving – Solves medium complexity problems with effective solutions. Asks good questions. Can see underlying or hidden problems and patterns. Looks beyond the obvious.
Results oriented – Can be counted on to exceed goals successfully. Is consistantly one of the top performers. Steadfastly pushes
Job ID 5532
# Positions 1
Category Claims Administration