Fallon Health NDM Operations Project Coordination Specialist 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 .
Brief summary of purpose:
Supports NDM contracting, provider relations and operations related to audit and research of contract configuration, claims payment and related issues. Provides support to NDM management in developing cross-departmental synergies, collaboration, and integration to eliminate inefficiencies and ensure optimal use of resources across the organization. Research quality and process improvement opportunities and initiate training and communication necessary to educate department staff. Oversees and performs various duties as needed to improve the efficiency of the department that allows Contract Managers and Provider Relations Representatives to focus on contract negotiations and external training and provider relationships respectively.
Primary Job Responsibilities:
Audit complex contract and adhoc configuration. Monitor initial claims payment to ensure alignment with negotiated provider contract rates.
Proactively collaborate with Contract Managers to help ensure negotiated contract terms adhere to policies and fit within system capabilities prior to contract execution.
Collaborate with Provider Relations on larger scale claims issues and identified payment error trends to assist in determining root cause and identifying a solution.
Assist with EVIPS auditing and reporting. Serve as back up EVIPS SME for administrator role functions.
Learn Quest software for required geo-access analysis related to network access and assist NDM analyst with related reporting.
Assist and back up NDM Analyst with other required regulatory reporting.
Support Internal Audit inquiries regarding claims payment.
Supports escalated Fallon Health Weinberg claims issues as needed.
Ability to complete necessary tasks for NDM associated with and required to move projects to timely and successful completion.
Assist and back up NDM Project Manager with other required reporting, projects, and/or expansion needs.
Develops and maintains strong partnerships with management at all levels of one or more business units.
Investigate program opportunities, evaluate using quantitative and trend analysis methodology.
Research and develop action plans to implement process improvements which includes initiating internal committees and project teams consisting of peer managers and individual subject matter experts.
Provides assistance to VP, training and backup to Contracting and NDM staff as needed to ensure optimum service to FH’s physicians, hospitals, and ancillary providers.
Bachelor’s Degree or equivalent training.
Requires experience working with cross-functional teams.
Relies on extensive experience and judgment to plan and accomplish goals.
Experience in analyzing and utilizing data to collaborate on business decisions.
At least 5 years’ experience in healthcare analysis and working knowledge of QNXT Trizetto platform.
Proficient in Microsoft Windows based office applications to include, Excel, Word, PowerPoint, and SharePoint.
Experience with eVIPS and Quest software system desirable.
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.
Posted Date 3 weeks ago (5/3/2022 1:15 PM)
Job ID 6836
# Positions 1
Category Network Development