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Fallon Health Remote Claims Processor - $17/hour 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 www.fallonhealth.org .

Brief summary of purpose:

The Claims Processor should have a thorough knowledge of claim entry in the core and external vendor processing systems – as well as a general knowledge of claims processing. Responsible for claims corrections involving data entry errors in core processing system and in the data entry vendor’s queue, processing of IT Fits member reimbursement requests and Customer Service cases, triage/assignment of requests for claim review and other claims documents, as well as other claims data entry and processing tasks as assigned. Ensures member and provider satisfaction by providing appropriate and timely processing of claims. Must be able to work on tasks both independently and as part of a team.


  • Meets or exceeds all department standards: productivity; quality; and attendance.

  • Responsible for claims editing on claims due to data entry errors in core processing system as well as in the data entry vendors queue

  • Responsible for processing various Data Integrity reports in accordance with department policies and procedures. Processes IT Fits! member reimbursement requests Claims data entry and processing tasks as assigned.

  • Evaluation and resolution of Customer Service cases related to reimbursement requests.

  • Review and validation of requests for claim review and other claims documents. Demonstrate solid judgment and discretion working with confidential information.

  • Comply with all department and company guidelines including all applicable laws and regulations.

  • Seeks assistance from Team Subject Matter Experts (SMEs), the Trainer and Claims Manager to ensure accuracy of adjudicating claims and to develop individual skills and grow professionally.

  • Work with teams inside and outside the department, and external customers as needed.

  • The above is intended to describe the general content of the requirments for the performance of the job. It is not to be construed as an exhaustive statement of duties, responsibilities or requirements


Qualification Requirements:

High school diploma, college degree preferred. Medical billing and coding or equivalent experience preferred.


  • Minimum of 1 year health care industry experience or equivalent

  • General knowledge of CPT, ICD-10, HCPCS coding guidelines and medical terminology preferred.

  • General ability to perform data entry and process claims efficiently and in a quality manner.

  • Ability to follow policy and procedural documentation

  • Some knowledge of claim processing from all perspectives (submissions, processing, dependencies)

  • MS Office and general PC skills.

  • Specific competencies essential to this position:

  • Analytical ability Gathers relevant information systematically. Considers issues or factors. Seeks input from others as appropriate.

  • Problem solving – Solves problems with effective solutions. Asks good questions. Can see underlying or hidden problems and patterns.

  • Results oriented – Can be counted on to exceed goals successfully. Steadfastly pushes self for results. *     *


MS Office, MS Excel, QNXT, Smart Data Solutions,

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 (3/12/2021 10:45 AM)

Job ID 6269

# Positions 1

Category Claims Administration