Fallon Massachusetts Jobs

mobile fallon logo

Job Information

Fallon Health Member Appeals & Grievances Coordinator in Worcester, Massachusetts


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.

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 www.fallonhealth.org .

Position Overview:

The FCHP Appeals and Grievance process is an essential function to FCHP’s compliance with CMS regulations, NCQA standards, other applicable regulatory requirements and member expectations. The FCHP Member Appeals & Grievances Coordinator serves to administrate the FCHP Appeals and Grievance process as outlined in the Plan Member Handbook/Evidence of Coverage, departmental policies and procedures, and regulatory standards. The Member Appeals & Grievances Coordinator serves as a liaison between FCHP members and FCHP with their complaints regarding denied claims, referrals, membership and benefit issues and any grievances regarding quality of care or service. The Member Appeals & Grievances Coordinator is responsible for presentation of the member appeal to the Plan Medical Director, Center for Medicare/Medicaid Services, contracted reviewer, and the Plan contracted external review agency in accordance with applicable laws, organization policies, and regulatory requirements. Thorough research, documentation, and corrective action planning must be established for each respective case and effectuation completed in accordance with existing regulations, policies and standards.


Job Responsibilities:

  • Administrate FCHP Standard and Expedited Appeals Processes as outlined in Member Handbook/Evidence of Coverage for all products, and in compliance with applicable NCQA standards and other state or federal regulatory requirements. Strict adherence to department turn-around time standards established in accordance with regulatory standards is required

  • Act as the primary investigator and contact person for member grievances and appeals, which includes sending the appropriate acknowledgement of the grievance/appeal, educating the member and/or member representative about the grievance/appeal, gathering all pertinent and relevant information from the member regarding the grievance/appeal, notifying the appropriate parties of the resolution and ensuring that all internal processes are completed to resolve the issue.

  • Conduct non-biased, accurate, timely and comprehensive investigation of all facts related to the grievance/appeal.

  • Thoroughly document all action taken on behalf of the member to resolve the grievance/appeal

  • Ensure that all grievances/appeals are processed in adherence to state and federal regulations (i.e. CMS, MassHealth, OPP), contractual obligations, NCQA guidelines and Plan policy.

  • Ability to interpret and operationalize multiple products and regulatory requirements and differences in each.

  • Ability to multitask and respond quickly and accurately to issues and concerns for members and internal departments.

  • Research, investigate and document all plans for corrective action.

  • On-call approximately one holiday (3-day) weekend per year and one 2-day weekend every 5 weeks and as needed. Available by cell phone to accept new expedited appeal requests and, where necessary, to present to the FCHP office to process request within applicable turn-around time standard.

  • Special projects as assigned by Management.

  • Conduct case management of legal/risk issues regarding member complaints, weighing interests of all customers, both internal and external

  • Adhering to FCHP confidentiality policy; document, research and review member complaints, involving quality of care or quality of service with appropriate clinical and/or administrative staff.

  • Work with Team Leaders, Department Managers, Department Chairs and/or Medical Director to resolve member complaints; formulate improvement measures and response to member; prepare written correspondence to member.

  • Forward all documentation involving member quality of care or quality of service complaints to FCHP administration and FCHP Quality Management Department.

  • Adhere to department standards for completion of member complaints.

  • Research and resolve system-wide issues, deficiencies, problems and formulate quality improvement measures.



College degree (B.S. or B.A.) or equivalent




1-3 years previous professional experience in related position (preferably in health care)

Additional Performance Requirements:

  • Excellent organizational and time management skills, including the ability to handle multiple tasks and projects in order to meet deadlines

  • Excellent written and verbal communication skills, including presentation skills

  • Strong attention to detail and ability to consistently produce quality work

  • Ability to meet deadlines as established by state and federal regulations, NCQA, contractual obligations and Plan policies

  • Ability to maintain a professional demeanor and confidentiality at all times

  • Ability to work with a variety of people and circumstances; strong ability to collaborate, negotiate, and reach agreement as appropriate

  • Ability to cope well with ambiguity and stressful situations

  • Excellent problem solving skills and ability to solve problems with creativity, consistency and flexibility

  • Ability to follow departmental and organizational guidelines, policies and procedures in processing grievances and appeals

  • Proficiency in Microsoft Word, Excel and Outlook. Ability to quickly learn and master new software applications

  • Excellent record management skills

  • Ability to work with minimal supervision and manage work effectively

  • Demonstrated sensitivity to the needs of every individual to be treated with respect and fairness

  • Knowledge of medical terminology

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 4 weeks ago (6/7/2022 4:50 PM)

Job ID 6887

# Positions 1

Category Customer Service