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Fallon Health Provider Specialist - Hybrid 3 days in Worcester office 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:

Respond to physician, hospital, ancillary provider inquiries and requests for services associated with the resolution of provider complaints relating to operational concerns, policy and procedures for Fallon Health products and subsidiaries. Understand Fallon Health policies and facilitate and the research required to resolve provider issues. Work collaboratively with internal departments to resolve provider items and look for process improvements. Validate and Update provider demographic and practice changes applicable to the assigned provider territory. Update provider demographic and non contractual changes in QNXT/eVips accurately and timely.


Primary Responsibilities

  • Receive daily calls and email correspondence from assigned physicians, hospitals, and ancillary providers requesting information and services.

  • Act as primary point of contact with assigned providers by promoting a one-stop customer service for escalated provider service issues. Escalations come from internal departments and external provider contacts.

  • Utilize appropriate internal resources in order to analyze and resolve issues.

  • Monitor status of QNXT cases thru to resolution status. Maintain detailed documentation within QNXT cases. Conduct proactive follow-up activities with provider and/or Fallon Health staff.

  • Validate data received by providers and update demographic and practice changes at the request of the assigned provider.

  • Adhere to departmental, corporate standards and policy and procedure (i.e., Fallon Health Service Level agreements) issue resolution timeframes, PUNKS, QNXT case inventory/assignments, etc.)

  • Assist and support the Provider Relations Representative on Provider enrollment initiatives.

  • Escalate critical issues and conflicts to Manager, Provider Data or Sr. Director, Benefit and Provider Configuration as appropriate.

  • Maintains assignments related to assigned territory, [i.e., internal Joint Operations Committee meetings, provider contract knowledge, PCP reports (changes, additions, deletions)], as appropriate.

  • Participate in external and internal provider meetings for assigned provider territory on a schedule or dependent upon urgency identified by Manager.

  • Manage all Provider Adds/Updates in the eVIPS application

  • Process any Group/Facility needs as identified by the Contracting Team in the eVIPS application



Bachelor’s degree or equivalent combination of training and experience


  • 2 years’ experience in a customer service role for a healthcare services organization

  • Proficiency with desktop computer applications, Microsoft Office package, mainframe knowledge (QNXT/eVips)

  • Knowledge of medical terminology/claims payment, ICD and CPT coding familiarity

  • Exemplary customer relations expertise

  • Clear concise written and verbal communication skillsSave (https://fchp.icims.com/icims2/servlet/icims2?module=AppJob&action=jobEdit&id=7570&tab=RQ_DESCRIPTION&hashed=2102748933#!)

  • Ability to manage, organize, document and prioritize multiple tasks simultaneously


QNXT, Microsoft Office package, eVIPS

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.

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.


Location US-MA-Worcester

Posted Date 2 months ago (4/23/2024 2:50 PM)

Job ID 7570

# Positions 1

Category Administrative Support Workers