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Fallon Health Provider Appeals Coordinator in Worcester, Massachusetts


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.


Responsible for the coordination and timely completion of provider appeals. Serves as a liaison between FCHP 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. This does not include appeals filed by providers on behalf of an FCHP member.


Primary Job Responsibilities:

  • Process provider appeals following documented process.

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

  • 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.

  • Present appeals to the Fallon Health Medical Director as appropriate. Serve as the liaison between the provider and Fallon Health for appeal cases.

  • Maintain provider appeal database and analyze data to produce monthly reports to management.

  • Other duties as assigned.


Education, Licenses, certification and experience requirements:

Education : Bachelors degree or equivalent combination of training and experience.

License: N/A

Certification: N/A

Experience: Minimum 2 years experience in the operational side of a managed care organization required. Claims, eligibility, care management or member/provider relations experience a plus.


  • Grasps complexities and perceives relationships among problems or issues.

  • Supports an atmosphere in which timely and high quality information flows smoothly between self and others.

  • Uses diplomacy and tact.

Job ID 5616

# Positions 1

Category Provider Relations