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Fallon Health Claims Processor Representative - Looking For A New Job Apply at Fallon 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.

Position Summary:

The Claims Processor should have a thorough knowledge of claim entry in the core and external vendor processing systems, as well as a general knowledge of claims processing. Responsible for claims corrections involving data entry errors in the data entry vendor’s queue, processing of member reimbursement requests and Customer Service cases, triage/assignment of requests for claim review and other claims documents, as well as other claims entry and processing tasks as assigned. Ensures member and provider satisfaction by providing appropriate and timely processing of claims. 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 claims editing on claims due to data entry errors.

  • Processes member reimbursement requests, including Part D and other prescription reimbursements in the core and external vendor processing systems.

  • Claims entry and processing tasks as assigned.

  • Evaluation and resolution of Customer Service cases related to reimbursement requests.

  • Review and validation of requests for claim review and other claims documents.

  • Demonstrate solid judgment and discretion working with confidential information.

  • Comply with all department and company guidelines including all applicable laws and regulations.

  • Seeks 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.


Qualification Requirements:

High school diploma, college degree preferred. Medical billing and coding or equivalent experience preferred.


  • Minimum of 1 year health care industry experience or equivalent

  • General knowledge of CPT, ICD-10, HCPCS coding guidelines and medical terminology preferred.

  • General ability to perform data entry and process claims efficiently and in a quality manner.

  • Ability to follow policy and procedural documentation

  • Some 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 issues or factors. Seeks input from others as appropriate.

  • Problem solving – Solves problems with effective solutions. Asks good questions. Can see underlying or hidden problems and patterns.

  • Results oriented – Can be counted on to exceed goals successfully. Steadfastly pushes self for results. *     *

Location US-MA-Worcester

Posted Date 2 weeks ago (1/13/2020 2:25 PM)

Job ID 5848

# Positions 1

Category Claims Administration