Fallon Health

  • Director, Provider Relations - Growing Health Plan with Health Services!

    Location US-MA-Worcester
    Posted Date 2 months ago(4/9/2018 4:27 PM)
    Job ID
    # Positions
    Provider Relations
  • Overview

    This role has recently opened up and it’s a great time to join Fallon Health as we anticipate a strong year. Our Provider Relations operation is central to success as Fallon continues to grow service offerings and membership in the Medicaid and Medicare space. Although Provider Relations has a strong foundation this is still a great opportunity for a new person to come in and make a big impact as we evolve in new business directions. This is a visible role as you and your team will represent the face of Fallon with all our providers and providers groups.


    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 fallonhealth.org.


    The Director, Provider Relations manages the activities of the Provider Relations function and its staff, which serves as Fallon Health Plan's liaison to the provider network as well as Fallons relationship with various contracted provider vendors. The Director also oversees the production of the provider newsletter as well as the education of providers for each of the various Fallon products and changes that are implemented. The Director works closely with other internal Fallon departments to resolve problems and issues that arise within the provider networks. Must have a solid understanding of provider fee schedules, claim policies and procedures as well as provider payment policies. The Director also leads the Provider Business Council.  


    • Foster a positive and team oriented spirit within the Network Development and Management Department.
    • Maintains positive and productive relationships with network providers through proactive relationship management and communication techniques; coaches and counsels those providers who are not meeting service standards.
    • Ensures that the provider network is well-trained on FCHP's standards and procedures and maintains a high quality service for members.
    • Responsible for hiring, developing, and retaining the highest quality Provider Relations staff. Provides work direction, mentoring, and training to all Provider Relations staff members.
    • Develops tracking and monitoring systems to ensure compliance and consistency of established standards and procedures.
    • Oversees communication to providers on administrative matters, including, but not limited to, new procedures. Work in concert with Fallon Corporate Communications to oversee the development and dissemination of all communication materials furnished to FCHP's providers. Communications materials include but are not limited to the Provider Manual, training materials, newsletters and announcements.
    • Review and resolve provider issues received from Provider Relations Department staff, direct communication with providers, government agencies or other internal Fallon sources. Examples of issues include, but are not limted to, claims, referrals, payment and appeal process and decisions.
    • Oversee the development, coordination, and presentation of the provider orientation program including program design and delivery of orientation training for primary care, specialist, hospital and ancillary providers on various healthcare administration topics, government compliance regulations and Fallon policies and procedures for products, benefits, claims, referrals, eligibility and utilization management.
    • Develop and oversee the vendor management team who has responsibility for all operational aspects and the relationship for of each of the provider vendors that contract with Fallon. Must have excellent problem solving skills and communication capabilities as well as creativity to protect Fallon’s interest but continue to keep a positive relationship.
    • Directs the work assignments of multi-disciplinary project teams.
    • Works with all FCHP departments to ensure a smooth running Provider Relations department.
    • Works with the Director of Contracting and Director of Provider Reimbursement and Data Management to coordinate provider servicing.




    • Education, Licenses, certification and experience requirements:
    • Education: Bachelors degree in related discipline with healthcare administration training required; Masters degree highly desirable.
    • Experience: 8-10 years progressively responsible experience in a healthcare provider relations/customer service role and minimum of 4 years in a leadership role with managerial responsibilities.
    • Proven ability to function independently and prioritize multiple tasks with limited supervision.
    • Excellent interpersonal and communication skills.
    • Managed care/healthcare delivery experience necessary.
    • Excellent knowledge of managed care finance/reimbursement mechanisms.
    • Thorough knowledge of government regulations as dictated by regulatory agencies including NCQA and CMS.
    • Proficiency with personal computer applications, Microsoft Office package and PowerPoint software. knowledge of QNXT is a plus
    • Demonstrated expertise in project management, negotiation and conflict resolution.


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