Fallon Health

  • Manager, Customer Service and Member Outreach

    Location US-MA-Worcester
    Posted Date 2 weeks ago(8/7/2018 4:15 PM)
    Job ID
    # Positions
    Customer Service
  • Overview

    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.

    Brief summary of purpose:

    Manage Customer Services team. Respond to customer inquiries for information and requests for service associated with the resolution of provider complaints, claim processing, appeals and grievance issues and various operational concerns. Interpret Fallon policies and facilitate the research required to resolve customer issues.


    • Manage and develop team:
      • Define roles and accountabilities for caseworkers, within the group and in the context of the broader process/operation in support of cross-functional efforts.
      • Develop and recognize the experience and knowledge/skills/abilities required for a successful casework team.
      • Define performance expectations and goals for team. 
      • Train and mentor team 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 team.

      • Evaluate team 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.
    • Provide subject-matter expertise to other areas of the company:
      • Establish and maintain an open communication channel with other contacts in other departments.
      • Meets with business owners and represent Customer Service. Take necessary information back to the team.

        Acts as a senior resource person/subject matter expert for team members in all areas of the work, including but not limited to: application of appropriate policy and procedures, etc.

      • Assists the team in resolving routine operational issues as they arise.  Serves as first level escalation with internal and external customers as necessary to resolve issues.
      • Assists with complex issues that fall within existing policy and procedures. Collaborates with manager in matters involving policy interpretation, exceptions to existing policy and procedure, etc.
      • Promotes use of established practices and procedures.
    • Manage the department’s business operation:
      • Implement, manage and refine business processes required to deliver expected business results.
      • Implement short-term staffing plans to ensure anticipated operational requirements are met. Monitor the workload and adjust staff assignments accordingly.
      • Ensure team has appropriate resources and highlights areas of need to Director/VP 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.
    • Establish and maintain effective channels of communication:
      • Establish and maintain an open communication channel with team.
      • Monitor effectiveness of communication with other groups (internal and external). Collaborates with Director/VP to implement changes as necessary to ensure an open, productive exchange of information.
      • Represent the department as requested.



    BA or BS in related discipline or equivalent combination of training and experience.



    Minimum of 2 years of experience in a customer service role for a healthcare services environment. Minimum 2 years of supervisory experience preferred.


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