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Fallon Health Provider Contract Configuration Manager in Worcester, Massachusetts


About Fallon Health:

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 delivers equitable, high-quality coordinated care and is continually rated among the nation’s top health plans for member experience, service, and clinical quality. 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 :

The manager will be responsible for the oversight and implementation of all contract types as well as adherence to service level agreements. Partners with the Contracting department to obtain contract inventory, as well as to determine feasibility of configuration prior to execution of a contract.

The manager will also be responsible for metric reporting, ongoing training curriculum enhancements and growth of the team.


Jo b Responsibilities:

  • Manage a team of analysts to effectively configure and test provider contracts

  • Advanced detailed experience with APR-DRG, MS-DRG, OPPS, APC Grouper, RBRVS and Pharmacy reimbursement methodologies

  • Detailed knowledge of hospital, ancillary and professional billing include CPT, HCPS, DRG and Ambulatory Surgery Coding

  • Collaborate with stakeholder to establish the criteria and timeframe to execute claim monitoring ties to specific configuration

  • Engages in analysis of various options and makes recommendations to leadership

  • Researches and stays current with change in CMS Medicare and Medicaid reimbursement models

  • Advances best practices in documentation, data quality and data management

  • Lead the continuous analysis and development of key data metrics that will be shared with key business stakeholders for making effective deci9sions

  • Provides guidance, mentoring and training to team

  • Participate in any audits (CMS, Internal, etc.) and provide remediation responses in short order when necessary

  • Experienced in both fee for service and value-based contracting configuration

  • Experience in developing quality assurance protocols and workflows

  • Support the development and execution of ad-hoc data requests needed to support various business needs

  • Trusted professional with a strong customer service orientation as well as the ability to work effectively with people at all levels is essential

  • Participate and lead strategic implementations as assigned

  • Ensure SOC and Model Audit Controls (MAR) are designed and functioning appropriately

  • Participate effectively in Committees as assigned

  • Develop and keep current existing Policies and Procedures

  • Other duties as assigned



Bachelor's degree preferred




  • Minimum 3-6 years working in the Healthcare industry with detailed configuration knowledge on Regulatory products such as Medicaid, Medicare, Duals, PACE, etc.

  • Proficient in pricing applications and code editing software

  • Results orientated – drives to meet business goal with quality and effectiveness

  • Systems thinking – must understand systems/people and the impact of business changes particularly as they affect internal and external business partners

  • Influencing others and ability to quickly build partnerships particularly those outside of direct reporting relationships

  • Ability to work independently with the executive level both internally and externally

  • Strong communication skills (formal and informal, written and verbal)

  • Ability to handle multiple demands- must be able to balance multiple priorities

  • Quick learner who can act as an advocate

  • Proficient in Microsoft product suite (i.e. Word, Excel, Power Point, etc.)

  • Project management skills

  • Problem solving based on understanding of system capabilities and business need with deep knowledge of systems at hand

  • Ability to collaborate with Operations and Finance to develop business process workflow and support documentation

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.

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 4 weeks ago (11/10/2022 12:33 PM)

Job ID 7052

# Positions 1

Category Provider Relations