Fallon Health

  • Recovery Specialist-COB (Coordination of Benefits) @ Fallon Health Insurance

    Location US-MA-Worcester
    Posted Date 4 months ago(9/5/2018 3:00 PM)
    Job ID
    # Positions
    Claims Administration
  • 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 Position:

    Process secondary COB claims utilizing other insurance company explanation of benefits (EOB). Process Motor Vehicle Accidents (MVA) and Workers Compensation (WC) claims utilizing letter received from other insurance company. Work with members, other insurance companies, employer groups and providers to determine primacy, following NAIC guidelines. Adhere to department goals for timeliness and accuracy.


    COB and Subrogation experience with both Commercial and Regulatory products and the associated regulations preferred.

    • Proven organization and communication skills
    • 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.
    • Demonstrated ability to handle incoming and outgoing phone calls from various sources, including members.
    • Serve as a subject matter expert and provide peer support in a mentoring or collaborative capacity in the office environment, whether it be training or answering of questions, as deemed appropriate by management.
    • 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.   
        • Process improvement abilities 



    High School Diploma, college degree preferred




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