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Fallon Health Insurance Provider Contract Configuration Analyst in Worcester, Massachusetts


About Fallon Health:

Fallon Health is a company that cares. We prioritize our members—always—making sure they get the care they need and deserve. Founded in 1977 in Worcester, Massachusetts, Fallon delivers equitable, high-quality coordinated care and is continually rated among the nation’s top health plans for member experience, service, and clinical quality. Today, guided by our mission of improving health and inspiring hope, we strive to be the leading provider of government-sponsored health insurance programs—including Medicare, Medicaid, and PACE (Program of All-Inclusive Care for the Elderly)— in the region. Learn more at fallonhealth.org or follow us on Facebook, Twitter and LinkedIn.

Brief Summary of Purpose :

Responsible for translating standard and complex and varied business needs into Fallon Health configuration rules. To be successful, must possess the technical expertise of the required operational phases of the business systems and analysis skills to translate the information accurately. Business acumen is essential to fully understand the implications of the configuration role on other interrelated businesses related to benefits and provider contracts.

The configuration work impacts the end result of Fallon’s health plans as well as the quality of claims operations, customer care operations, and cost containment & recovery operations. With a strong dedication to excellent work quality, 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.

The Contract configuration team is responsible to ensure that claims are paid correctly based upon the contract configuration, medical policies, reimbursement policies, claims editing policies, EOHHS and CMS requirements.


Job Responsibilities :

  • Performs configuration based upon varying reimbursement methodologies such as APR-DRG, MS-DRG, OPPS, APC Grouper, RBRVS and Pharmacy

  • Maintains detailed knowledge of hospital, ancillary and professional billing include CPT, HCPS, DRG and Ambulatory Surgery Coding

  • Researches and stays current with change in CMS Medicare and Medicaid reimbursement models

  • Advances best practices in documentation, data quality and data management

  • Adheres to contract quality metrics

  • Participates in any audits (CMS, Internal, etc.) and provides remediation responses in short order when necessary

  • Executes accurate fee for service and value-based contracting configuration

  • Supports the development and execution of ad-hoc data requests needed to support various business needs

  • Ensures SOC and Model Audit Controls (MAR) are designed and functioning appropriately

  • Develops and keeps current existing Policies and Procedures

  • Completes all edits and call tracking cases are completed within applicable SLA

  • Analyzes code publications in addition to new or updated policies to assess and respond to impact on configuration and related processes

  • Explores process improvement opportunities as well as mentors new and current team members

  • Expedites implementation delays and escalates issues to management as appropriate

  • Serves as the subject matter expert as it relates to configuration tasks and manages issues to a positive outcome

  • Actively participates, and facilitates as needed, in meetings related to contract configuration

  • Develops and executes test plans as is relates to core system upgrades such as QNXT or Symplir

  • Maintains current knowledge of pricing applications and code editing software

  • Executes upon all business goals with quality and effectiveness

  • Maintains thorough and concise documentation for tracking

  • Assists with the development of configuration standards and best practices

  • Handles fluctuating volumes of work and prioritizes work to meet deadline and business needs independently

  • Escalates identified issues, makes recommendations, and implements configuration changes to improve the accuracy and efficiency of processes

  • Works independently with the Network Development team to understand and implement contract requirements

  • Maintains current knowledge of industry standard code sets, government regulations as mandated by the regulatory agencies such as NCQA, CMS, NPI, etc.

  • Other duties as assigned



Bachelor’s degree in business or equivalent business experience




  • Minimum 4-7 years working in the Healthcare industry with detailed provider contract configuration knowledge on Regulatory products such as Medicaid, Medicare, Duals, PACE, etc.

  • Systems thinking – must understand systems/people and the impact of business changes particularly as they affect internal and external business partners

  • Strong communication skills (formal and informal, written and verbal)

  • Ability to handle multiple demands - must be able to balance multiple priorities (i.e., contract configuration, working edits, etc.)

  • Quick learner who can act as an advocate

  • Proficient in Microsoft product suite (i.e., Word, Excel, Power Point, etc.)

  • Highly organized problem solver with understanding of system capabilities and business need; deep knowledge of systems at hand

  • 3-7 years’ experience with QNXT or similar database is required in Healthcare Administration

  • Prior experience working with and responding to customer service cases, claims administration, enrollment or appeals and grievances related to inaccurate configuration information

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 1 month ago (8/24/2023 8:48 AM)

Job ID 7395

# Positions 1

Category Other