Administrative Support - Provider Appeals

Administrative Support - Provider AppealsUS-MA-WorcesterJob ID: 6959Type: Full Time of Openings: 1Category: Provider RelationsFallon Health - Corp HQOverviewAbout 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 .Brief Summary of Purpose:Responsible for the receipt of and organization and tracking of provider appeals. Serves as liaison between Fallon Health and contracted providers regarding appeals related to filing limit, claim denials, claim payment, retrospective referrals, administrative inpatient days and other issues for which the provider is liable. This does not include appeals filed by providers on behalf of a Fallon Health member.ResponsibilitiesJob Responsibilities:Responsible for processing all incoming provider appeal mail, as well as forwarding all initial claim submissions, claim adjustments, non-contracted provider appeals and other miscellaneous mail to appropriate departments.Tracking all provider appeals as well as determining type of itial review of all appeals (including but not limited to determining if appeal was received within submission timeframes, if claims has already been paid, if member appeal, etc.)Processing of reports which produce all correspondence to providers related to appeal determinations and untimely requests, as well as sending those correspondence to providers.Filing of individual provider appeal files in accordance with department standards.Processing of reports which produce all correspondence to providers related to appeal determinations and untimely requests, as well as sending those correspondence to providersMaintain provider appeal database and analyze data to assist Provider Appeal Coordinator in production of monthly reports forwarded to Management.Other duties as assigned.QualificationsEducation: High school diplomaExperience: Minimum 2 years experience in the operational side of a managed care organization petencies:Gathers relevant information systematically.Can see underlying or hidden problems and patterns.Asks good questions.Additional Performance Requirements:Must be proficient with personal computer applications, including Microsoft Office.Knowledge of QNXT preferred.Excellent organizational and communication skills.Strong interpersonal and customer service skills.Must be detail-oriented.Knowledge of claims protocol, referral and authorization process, benefit coverage and provider contracts preferred.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. PM16PI188537298

Created: 2025-11-15