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 Position:
The Claims Specialist should have advanced claim processing knowledge at the highest complexity level. Knowledge of all Claim Specialist A and B competencies plus added responsibility for adjusting claims, working provider and member cases, and resolving edits that fire on adjustments. Advanced understanding of authorizations, benefits, contracts, enrollments, fee schedules and Fallon Health’s payment policies. Thorough knowledge of claims processing configuration and QNXT functionality. Ensures member and provider satisfaction by providing appropriate and timely processing of high complexity cases and adjustments (multi-step resolution). Monitors and resolves high volume of adjustments for all lines of business and ensures compliance with established guidelines. Must be able to work on tasks both independently and as part of a team.