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Fallon Health Provider Specialist - Hybrid 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:

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.


Job 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 skills

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

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 1 month ago (11/1/2022 3:59 PM)

Job ID 7099

# Positions 1

Category Provider Relations