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.
Summary:
Under the direction of the Market Research Manager, supports Fallon by making Welcome/Outreach calls to members and/or survey calls to members or providers. Handles confidential patient/member information. Uses strong verbal communication skills and demonstrates excellent telephone communication skills. Understands the importance of leaving a positive impression on any member with whom they come into contact. When necessary, assists member through the creation of formal research cases.
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 Overview:
The Fallon Health Appeals and Grievance process is an essential function to Fallon Health’s compliance with CMS regulations, NCQA standards, other applicable regulatory requirements and member expectations. The Fallon Health Member Appeals & Grievances Coordinator serves to administrate the Fallon Health Appeals and Grievance process as outlined in the Plan Member Handbook/Evidence of Coverage, departmental policies and procedures, and regulatory standards. The Member Appeals & Grievances Coordinator serves as a liaison between Fallon Health members and Fallon Health with their complaints regarding denied claims, referrals, membership and benefit issues and any grievances regarding quality of care or service. The Member Appeals & Grievances Coordinator is responsible for presentation of the member appeal to the Plan Medical Director, Center for Medicare/Medicaid Services, contracted reviewer, and the Plan contracted external review agency in accordance with applicable laws, organization policies, and regulatory requirements. Thorough research, documentation, and corrective action planning must be established for each respective case and effectuation completed in accordance with existing regulations, policies and standards.
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:
The Provider Data Specialist conducts outbound calls to providers to validate provider data in Fallon Health’s core record keeping system. Post validation, Provider Data Specialist will document calls taken identifying data changes obtained from provider. Provider Data Specialist will make required changes post documentation to provider records as required within service level agreements.
Key Accountabilities:
- Contact providers for updates to provider data
- Validate provider data
- Update provider data- determine completeness of forms prior to entry. Research any misleading or missing data fields and escalate any unresolved issues to Manager.
Fantastic Call Center & Advancement Opportunities in Health Care!
The Opportunity:
We are currently hiring for a 9:30 am - 6:00 pm shift with one evening per month and occasional weekends between October - March.
It’s an exciting time to join Fallon Health as we experience growth and expansion with new services and products. There are many great opportunities within our organization starting with joining our Member Services team. Member Services offers a very unique opportunity to interact with nearly every facet of the FCHP organization including our products, services, functions, and people.
Among the most rewarding and fulfilling parts of working on this team is representing Fallon Health as the face of the organization; the single point of contact for our valued providers and members. Think of yourself as an FCHP brand and membership ambassador. As a representative of Fallon Health, you will be an advocate to members reaching out for support; providing this highly valued service fielding calls and consultatively troubleshooting inquiries, you will be solving their needs and concerns.
In addition to the diverse responsibilities outlined below, a spot on this team also represents one of the best places to grow your career. With demonstrated initiative and strong performance, you will gain exposure across a multitude of functions and endless opportunities for advancement. Member Services has proven to be a launching pad of development that has translated into long term careers with advancement opportunities throughout the company in a number of different key area’s such as; Sales and Marketing, Provider Relations, Care Services, Pharmacy and other functions of the operation.
As a brand champion and valued member ambassador you will get extensive training and support through a skill based progression training program that includes a blended learning curriculum and personalized coaching plan. We are always looking for top talent in these roles so feel free to pass this along to friends, family and colleagues that you think qualify.