Fallon Health

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Supervisor, Claims Administration

Supervisor, Claims Administration

Job ID 
# Positions 
Posted Date 
Claims Administration

More information about this job


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.


  • Meet or exceed all department standards: productivity; quality; and metrics.
  • Determine short term and long-term resources (systems, skills needed, capacity planning, etc.) to meet future business needs.
  • Participate in cost/benefit analysis of operational changes in support of future business requirements.
  • Regularly track group/departmental costs, ensuring these are managed within budget. Employ cost containment measures while retaining quality and efficient operations and a productive, healthy work environment. Anticipate expenses and identify potential budgetary concerns to Senior Director of Claims and Configuration.
  • Regularly analyze and report on the productivity, quality and effectiveness of the operations in comparison to established performance metrics. Identify areas of improvement and recommend resolution.
  • Work cross-functionally to ensure operations and changes are well integrated.
  • Proactively seek feedback from other groups on the impact and effectiveness of current and changes to operations.
  • Implement, manage and refine business processes required to deliver expected business results.
  • Monitor the workload and adjust staff assignments accordingly.
  • Ensure team has appropriate resources and highlights areas of need to Senior Director for resolution.
  • Ensure the timely and accurate exchange of information/data with relevant stakeholders of the operation.
  • Monitor the work environment and the business operation.  Address concerns that may affect the morale and/or operational effectiveness of the group.
  • Define roles and accountabilities for staff, within the group and in the context of the broader process/operation in support of cross-functional efforts.
  • Hire for, develop and recognize the experience and knowledge/skills/abilities required for a successful team.
  • Provide for the orientation and welcome of new staff.
  • Define performance expectations and goals for staff. 
  • Train and mentor staff on the application of policy and procedures, use of supporting systems/applications, appropriate soft skills: time management, etc.
  • Monitor work of individual staff for efficiency, effectiveness and quality.  Provide ongoing constructive feedback and guidance to staff.
  • Evaluate staff on achievement of goals and deliverables and assessment of competencies. Help staff progress in their careers to the benefit of the department and broader organization. Manage the resolution of performance issues in consultation with Human Resources as appropriate.
  • Proactively communicate with other departments to ensure cross-functional concerns are identified and effectively addressed.



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.