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 Administration Supervisor will be responsible for the supervising junior level claims staff.
The Supervisor 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 ensuring staff have the ability to perform claims corrections involving data entry errors in the data entry vendor’s queue, processing of member reimbursement requests and Customer Service cases, triage/assignment of requests for claim review and other claims documents, as well as other claims entry and processing tasks as assigned. Ensures member and provider satisfaction by providing appropriate and timely processing of claims.
Bachelor degree in business or other applicable field.
Minimum of five (5) years of claims and health care administration and/or managed care experience with managerial experience.
Strong claims knowledge of health insurance industry with all product lines (Medicare, Medicaid, Commercial, ASO, PPO, PACE, Duals, FHW, etc.)
Extensive knowledge of claims policies and procedures, including regulatory requirements and industry standards from AMA, CMS and CCI Edits.
Strong Communication and Presentation skills.
Strong Analytical Ability
Extensive knowledge of federal and state regulations, legislation and laws, auditing reports and system functions; comparing functions with established standards.
Ability to and experience in forecasting.
Ability to perform root causal analysis and impact assessments with the goal of mitigation and/or process improvements.