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Fallon Health Provider Appeals Coordinator - Hybrid/Remote in Worcester, Massachusetts


About us:

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 Health delivers equitable, high-quality, coordinated care and is continually rated among the nation’s top health plans for member experience, service, and clinical quality. We believe our individual differences, life experiences, knowledge, self-expression, and unique capabilities allow us to better serve our members. We embrace and encourage differences in age, race, ethnicity, gender identity and expression, physical and mental ability, sexual orientation, socio-economic status, and other characteristics that make people unique. 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 the coordination and timely completion of provider appeals. Serves as a liaison between Fallon Health and contracted and non-contracted providers with appeals regarding filing limit appeals, claim denials, claim payment, retrospective referrals, administrative inpatient days and other issues for which the provider is liable.


Primary Job Resposibilities

  • Process provider appeals following the documented process.

  • Ability to review correspondence and system data to establish facts and draw valid conclusions consistent with applicable policy and procedures.

  • Manage and coordinate assigned provider appeals with a timely resolution according to internal measures/targets.

  • Present appeals to the Fallon Health Medical Director(s) as appropriate.

  • Serve as the liaison between the provider and Fallon Health appeal cases.

  • Maintain provider appeal database and non-contracted provider spreadsheet.

  • Correspond with providers during the appeals process; included but not limited to acquisition of medical records, status updates and final determination as indicated in the provider appeals process.

  • Identify automation opportunities to reduce manual work resulting in improved efficiencies

  • Assist with preparation for a successful CMS Program Audit according to NCP appeals timeliness, accuracy, and quality validation

  • Print and mail provider notification letters at the FH corporate office located at 10 Chestnut Street, Worcester, MA several times per month or as needed, as designated through a rotational in-office calendar or at the direction of a supervisor or manager.



Bachelor's degree or equivalent combination of training and experience




2 years related experience, preferably in health care

COVID-19 Vaccination:

With the end of the Global Coronavirus COVID-19 Pandemic, Fallon Health no longer requires all employees to be vaccinated against COVID-19 except for employees who are in jobs that under state and federal laws, regulations and policies are required to be vaccinated and/or they are in Member/participant facing positions.

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 3 weeks ago (5/22/2024 12:38 PM)

Job ID 7593

# Positions 1

Category Provider Relations