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Fallon Health Provider Appeals Specialist 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: Responsible for the receipt of and organization and tracking of provider appeals. Serves as liaison between Fallon Health and contracted providers regarding appeals related to filing limit, 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 Fallon Health member.

Responsibilities

  • Responsible for processing all incoming provider appeal mail, as well as forwarding all initial claim submissions, claim adjustments, non-contracted provider appeals and other miscellaneous mail to appropriate departments.

  • Tracking all provider appeals as well as determining type of appeal.

  • Initial review of all appeals (including but not limited to determining if appeal was received within submission timeframes, if claims has already been paid, if member appeal, etc.)

  • Processing of reports which produce all correspondence to providers related to appeal determinations and untimely requests, as well as sending those correspondence to providers.

  • Filing of individual provider appeal files in accordance with department standards.

  • Processing of reports which produce all correspondence to providers related to appeal determinations and untimely requests, as well as sending those correspondence to providers

  • Maintain provider appeal database and analyze data to assist Provider Appeal Coordinator in production of monthly reports forwarded to Management.

  • Other duties as assigned.

Qualifications

Education: High school diploma

Experience: Minimum 2 years experience in the operational side of a managed care organization required.

Competencies:

  • Gathers relevant information systematically.

  • Can see underlying or hidden problems and patterns.

  • Asks good questions.

Additional Performance Requirements:

Must be proficient with personal computer applications, including Microsoft Office..

Knowledge of QNXT preferred.

Excellent organizational and communication skills.

Strong interpersonal and customer service skills.

Must be detail-oriented.

Knowledge of claims protocol, referral and authorization process, benefit coverage and provider contracts preferred.

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 1 month ago (9/25/2020 12:48 PM)

Job ID 6085

# Positions 1

Category Provider Relations

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