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 Claims Examiner should have thorough claim processing knowledge at a complex level. Knowledge of all Claim Specialist A competencies plus added responsibility for resolving pended claims. Thorough understanding of authorizations, benefits, contracts, enrollment and fee schedules. Ensures member and provider satisfaction by providing appropriate and timely processing of involved cases and claims (multi-step resolution). Monitors and resolves high volume of claims for all lines of business, as well as claims for performance guarantee groups and high dollar claims, to minimize late payment interest penalties and ensure compliance with established guidelines. Must be able to work on tasks both independently and as part of a team.
High school diploma, college degree preferred. Medical billing and coding or equivalent experience preferred.
Resources (systems, etc.)used in performing role
MS Office, QNXT, Caremark, Smart Data Solutions, Burgess, Multiplan, FairHealth, MicroDyn, FlexCare, MARx