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Fallon Health Provider Relations Representative 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.

Summary :

Serve as primary liaison between Fallon Health and all contracted and limited non-contracted physicians/providers, hospitals and ancillary providers within an assigned territory. Monitor provider business operations to ensure compliance with Fallon Health's documented standards, policy and procedures and government regulations.


  • Serve as primary FCHP contact for providers to resolve issues relating to the administration and operation of providers' contracted services..

  • Orient and educate primary care, specialist, hospital and ancillary providers by conducting physician and office staff visits. Educate providers on FCHP policies and procedures to include products, benefits, claims, referral and eligibility verification processes, utilization management guidelines, etc. Activities include conducting both individual and large group education sessions on a continual basis.

  • Engage necessary FCHP staff members and conduct investigative research to resolve provider issues. Work collaboratively with internal partners to reduce provider issues and implement long term solutions to problems identified.

  • Escalate conflicts to Manager of Provider Relations and when appropriate Director, Provider Relations.

  • Monitor and counsel providers on disciplinary actions and non-compliance issues.

  • Develop and maintain positive and productive rapport with FCHP providers through proactive relationship management and communications..

  • Assist in the development of provider training material and provider tools. Deliver provider training including new provider orientations, individual and/or group training on various healthcare administration topics, government compliance regulations and FCHP policies and procedures for products, benefits, claims, referral, and eligibility and utilization management.

  • Co-lead internal and external Joint Operations Committee meetings with contract managers.

  • 30-50% Travel is required.



  • Bachelor’s degree in related discipline with healthcare administration training highly desirable


  • Valid Driver’s License and Clean Driving Record Required


  • 3-5 years’ experience

  • Thorough knowledge of government regulations as dictated by regulatory agencies, including NCQA (National Committee on Quality Assurance) and CMS (Centers for Medicare & Medicaid Services).

  • Proficiency with desktop computer applications, Microsoft Office package and Mainframe knowledge (i.e. QNXT, IDX etc.)

  • Training curriculum development and platform presentation techniques.

  • Exemplary customer relations skills.

  • Clear and concise written and verbal communication skills.

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 (8/24/2021 1:00 PM)

Job ID 6477

# Positions 1

Category Provider Relations