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Fallon Health Member Appeals & Grievances Intake Administrator in Worcester, Massachusetts

Overview

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 fallonhealth.org.

Brief Summary of Purpose:

The Member Appeals & Grievances Intake Administrator is responsible for triaging and assigning all incoming appeals and grievances addressed to the Member Appeals & Grievances Department. The Intake Administrator will also be provide administrative support to the department.

Responsibilities

  • The Member Appeal & Grievance Intake Administrator reviews and researches all incoming correspondence addressed to the Member Appeals & Grievances Department. Grievances and appeals are triaged to coordinators and miscellaneous correspondence is redirected, as appropriate.

  • Providing administrative assistance in support of the Board of Hearings (BOH) process to include hearing packet preparation, reviewing of materials, and tracking and monitoring hearing decisions.

  • All requests for expedited appeal are brought to the immediate attention of a Member Appeal & Grievance Coordinator

  • Administrate the triage of appeals and grievances which includes:

  • Identifying whether the request is subject to the Appeals Procedure (i.e., has there been an initial Plan determination, etc.)

  • Completing entry of case into the QNXT call tracking system

  • Issuing an acknowledgement letter

  • Identifying the need for Personal Representative Authorization form, Medical Record Release Authorization form, or Provider Payment Waiver form and requests such documentation as necessary

  • Acquiring all Fallon Health documentation relevant to the appeal request. The Intake Administrator interfaces with internal departments including Care Services and Claims Department, as necessary

  • Assigning case files to the department staff for case management

  • Managing incoming faxes and member specific data, routing to the appropriate staff member

  • Producing, maintaining and distributing reports/calendars utilized by the team to assist in workload planning

  • Processes department incoming/outgoing mail per established workflows in a timely and accurate manner

  • Providing administrative/clerical support to the department which may include acquisition of medical records from providers.

  • Retrieving messages from email and voice mailbox, routing to the appropriate staff member

  • Providing back-up to Team members including telephone coverage, as needed

  • Photocopy and compilation of appeal case file when necessary

  • Completion of request for additional information from external review agency

  • Responsible for additional clerical/administrative responsibilities at the discretion of the Director or Manager

Qualifications

Education

2 years college education (or knowledge of healthcare field equal to 2 years college preparation)

Experience

2 years related experience, preferably in health care and/or managed health care system

PM16

Job ID 5754

# Positions 1

Category Customer Service

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