Fallon Health

  • Provider Relations Coordinator - Health Insurance and Health Services!

    Location US-MA-Worcester
    Posted Date 3 weeks ago(10/29/2018 1:31 PM)
    Job ID
    # Positions
    Provider Relations
  • 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 www.fallonhealth.org.


    Brief summary of purpose:

    Respond to physician, hospital, ancillary provider inquiries and requests for services associated with the resolution of provider complaints relating to operational concerns, policy and procedures for Fallon Health products and subsidiaries. Understand Fallon Health policies and facilitate and the research required to resolve provider issues. Work collaboratively with internal departments to resolve provider items and look for process improvements. Provide education and re-education as appropriate. Validate and initiate provider demographic and practice changes applicable to the assigned provider territory. Update provider demographic and non contractual changes in QNXT/eVips accurately and timely.




    • Receive daily calls and email correspondence from assigned physicians, hospitals, and ancillary providers requesting information and services.
    • Act as primary point of contact with assigned providers by promoting a one-stop customer service for escalated provider service issues. Escalations come from internal departments and external provider contacts.
    • Utilize appropriate internal resources in order to analyze and resolve issues.
    • Monitor status of QNXT cases thru to resolution status.   Maintain detailed documentation within QNXT cases. Conduct proactive follow-up activities with provider and/or Fallon Health staff.
    • Validate data received by providers to initiate demographic and practice changes at the request of the assigned provider. All non contractual changes will be made directly into QNXT/eVips by Provider Coordinators.
    • Adhere to departmental, corporate standards and policy and procedure (i.e. Fallon Health Service Level agreements) issue resolution timeframes, PUNKS, distribution memos, QNXT case inventory/assignments, etc.)
    • Assist and support the Provider Relations Representative on project assignments such as claims analysis and referral issues to resolve issues, welcome letters and in the education of providers on Fallon Health policy and procedures.
    • Escalate critical issues and conflicts to Manager, Provider Data or Sr.Director, Benefit and Provider Configuration as appropriate.
    • Maintains assignments related to assigned territory, [i.e., internal Joint Operations Committee meetings, provider contract knowledge, PCP reports (changes, additions, deletions)], as appropriate.
    • Participate in external and internal provider meetings for assigned provider territory on a schedule or dependent upon urgency identified by Manager.




    Bachelor’s degree or equivalent combination of training and experience



    • 2 years’ experience in a customer service role for a healthcare services organization
    • Proficiency with desktop computer applications, Microsoft Office package, mainframe knowledge (QNXT/eVips)
    • Knowledge of medical terminology/claims payment, ICD and CPT coding familiarity
    • Exemplary customer relations expertise
    • Clear concise written and verbal communication skills
    • Ability to manage, organize, document and prioritize multiple tasks simultaneously


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