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.
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 Fallon Health Member Appeals & Grievances 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 Member Appeals & Grievances 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 Member Appeals & Grievances 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.
Education: College degree (B.S. or B.A.) or equivalent
Experience: 1-3 years previous professional experience in related position (preferably in health care)