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Fallon Health Senior Coordinator, Member Appeals & Grievances 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.


The Fallon Health Appeals and Grievance process is an essential function to Fallon Health’s compliance with CMS regulations, NCQA standards, other applicable regulatory requirements and member expectations. The Senior Coordinator serves to administrate the Fallon Health Appeals and Grievance process as outlined in the Plan Member Handbook/Evidence of Coverage, departmental policies and procedures, and regulatory standards. The Senior Coordinator serves as a liaison between Fallon Health members and Fallon Health with their complaints regarding denied claims, referrals, membership and benefit issues and any grievances regarding quality of care or service. The Senior Coordinator is responsible for presentation of the member appeal to the Plan Medical Director, Center for Medicare/Medicaid Services, contracted reviewer, and the Plan contracted external review agency in accordance with applicable laws, organization policies, and regulatory requirements. Thorough research, documentation, and corrective action planning must be established for each respective case and effectuation completed in accordance with existing regulations, policies and standards.


Primary Job Responsibilities:

  1. Administrate Fallon Health Standard and Expedited Appeals Processes as outlined in Member Handbook/Evidence of Coverage, and in compliance with applicable NCQA standards, CMS, MassHealth and other state or federal regulatory requirements. Strict adherence to department turn-around time standards, established in accordance with regulatory standards, is required.

  2. On-call

  3. Conduct case management of legal/risk issues regarding member complaints, weighing interests of all customers, both internal and external.

  4. Adhering to Fallon Health confidentiality policy; document, research and review member complaints, involving quality of care or quality of service with appropriate clinical and/or administrative staff.

  5. Work with Department Managers and Medical Director to resolve member complaints; formulate improvement measures and response to member; prepare written correspondence to member.

  6. Forward all documentation involving member quality of care or quality of service complaints to Fallon Health’s administration and Fallon Health’s Quality Management Department.

  7. Adhere to department standards for completion of member complaints.

  8. Research and resolve system-wide issues, deficiencies, problems and formulate quality improvement measures.

  9. Assist Department Managers in departmental audit function;

  10. Meet regularly with Department Manager and management team to identify and discuss department and/or identified system issues directly effecting member and staff satisfaction to recommend plans for improvement measures;

  11. Work with Department Manager and management team in developing and implementing specific work plans for improvements in department work processes;

  12. Serve in a senior capacity providing guidance, training, and/or assistance to staff regarding processing of appeals and grievances;

  13. Has proven competencies in entry level coordinator and Coordinator II position.

  14. Commands overall understanding of Department goals and processes, including introductory database management and case triage process. Understands interdepartmental processes and relationships.

  15. Special projects as assigned by Department Manager.


Education, Licenses, certification and experience requirements:

Education: Bachelor’s Degree or equivalent experience in managed health care required

License: N/A

Certification: N/A

Experience: Subject matter expert in Appeals & Grievances

Job ID 5551

# Positions 1

Category Customer Service