Fallon Health

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Claims Specialist - Looking for growth? Try Fallon Health Insurance!

Claims Specialist - Looking for growth? Try Fallon Health Insurance!

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.


Position Summary:

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.


  • Consistently meets or exceeds all department standards: productivity; quality; and attendance.
  • Responsible for resolving a high volume of adjustments for all lines of business.
  • Advanced knowledge of Fallon Health policies, protocols and procedures.
  • Advanced understanding of authorizations, benefits, contracts, enrollments, fee schedules and Fallon Health’s payment policies.
  • Resolution of complex and high dollar adjustment requests, member and provider cases and adjustment projects.
  • Develop and execute testing plans with Claims scenarios for upgrades, enhancements, defect remediation, new configuration, and other projects as needed.
  • Ensures accuracy and timeliness of adjustment processing to minimize late payment interest penalties and ensure compliance with established guidelines.
  • Evaluation and resolution of Customer Service cases related to adjustment requests.
  • Demonstrate solid judgment and discretion working with confidential information.
  • Comply with all department and company guidelines including all applicable laws and regulations.
  • Demonstrates ability to perform independently in conformance with written instructions, established timeframes, and pre-determined priorities.
  • Requires minimal assistance from Team Subject Matter Experts (SMEs), the Trainer and Claims Manager to ensure accuracy of adjudicating claims and to develop individual skills and grow professionally.
  • Work with teams inside and outside the department, and external customers as needed.
  • The above is intended to describe the general content of the requirments for the performance of the job. It is not to be construed as an exhaustive statement of duties, responsibilities or requirements



High school diploma, college degree preferred. Medical billing and coding or equivalent experience preferred.



        • Minimum of 3 years health care industry experience or equivalent
        • Advanced knowledge of CPT, ICD-10, HCPCS coding guidelines and medical terminology preferred.
        • Demonstrated ability to enter and process high complexity claims efficiently and in a quality manner.
        • Advanced understanding of complex claim processing from all perspectives (submissions, processing, dependencies)
        • MS Office and general PC skills.
        • Specific competencies essential to this position:
        • Analytical ability – Gathers relevant information systematically. Considers a full range of issues or factors.  Grasps complexities and perceives relatioinships among problems or issues. Seeks input from others as appropriate.
        • Problem solving – Solves high complexity problems with effective solutions. Asks good questions. Can see underlying or hidden problems and patterns.  Looks beyond the obvious.
        • Results oriented – Can be counted on to exceed goals consistantly. Is consistantly one of the top performers. Steadfastly pushes self for results.