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Overview

About us:

Fallon Health is a company that cares. We prioritize our members—always—making sure they get the care they need and deserve. Founded in 1977 in Worcester, Massachusetts, Fallon Health delivers equitable, high-quality, coordinated care and is continually rated among the nation’s top health plans for member experience, service, and clinical quality. We believe our individual differences, life experiences, knowledge, self-expression, and unique capabilities allow us to better serve our members. We embrace and encourage differences in age, race, ethnicity, gender identity and expression, physical and mental ability, sexual orientation, socio-economic status, and other characteristics that make people unique. Today, guided by our mission of improving health and inspiring hope, we strive to be the leading provider of government-sponsored health insurance programs—including Medicare, Medicaid, and PACE (Program of All-Inclusive Care for the Elderly)— in the region. Learn more at fallonhealth.org or follow us on Facebook, Twitter and LinkedIn.

Brief summary or purpose:

Fallon Health (FH) Appeals and Grievance process is an essential function to FH’s compliance with CMS regulations, NCQA standards, other applicable regulatory requirements and member expectations. The FH Member Appeals and Grievance Intake Administrator serves to administer the FH Appeals and Grievance process as outlined in the FH Member Handbook/Evidence of Coverage, departmental policies and procedures, and regulatory standards. The Member Appeals & Grievances Intake Administrator is responsible for triaging and assigning all incoming appeals and grievances addressed to the Member Appeals & Grievances Department. This position will also provide administrative support to the department.

Responsibilities

• Administer FH Standard and Expedited Appeals Processes as outlined in Member Handbook/Evidence of Coverage for all products, and in compliance with applicable NCQA standards and other state or federal regulatory requirements. Strict adherence to department turn-around time standards established in accordance with regulatory standards is required.

• Act as the initial investigator and contact person for member grievances and appeals, which includes, sending the appropriate acknowledgement of the grievance/appeal, educating the member and/or member representative about the grievance/appeal, gathering all pertinent and relevant information from the member regarding the grievance/appeal.

• Print, mail, and triage letters at the FH corporate office located at 10 Chestnut Street, Worcester, MA.

• Identifying the need for Personal Representative Authorization form, Medical Record Release Authorization form, or Provider Payment Waiver form and requests such documentation as necessary.

• Assigning case files to the department staff for case management.

• Managing incoming faxes and member specific data, routing to the appropriate staff member.

• Producing, maintaining, and distributing reports/calendars utilized by the team to assist in workload planning.

• Processes department incoming/outgoing mail per established workflows in a timely and accurate manner.

• Providing administrative/clerical support to the department which may include acquisition of medical records from providers.

• Retrieving messages from email and voice mailbox, routing to the appropriate staff member.

• Photocopy and compilation of appeal case file when necessary.

• Completion of request for additional information from external review agency.

• Responsible for additional clerical/administrative responsibilities at the discretion of the Director or Manager.

• Providing administrative assistance in support of the Board of Hearings (BOH) process, including preparation of hearing packets, reviewing of materials, as well as tracking and monitoring hearing decisions.

• Ensure that all grievances/appeals are processed in adherence to state and federal regulations (i.e., CMS, MassHealth, OPP), contractual obligations, NCQA guidelines and FH policy.

Qualifications

Education:

College Degree (B.S. or B.A.) or equivalent

License/Certifications:

Reliable transportation required

Experience:

2 years college education (or knowledge of healthcare field equal to 2 years college preparation)

Fallon Health provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.

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**Location** _US-MA-Worcester_

**Posted Date** _3 weeks ago_ _(4/14/2025 1:20 PM)_

**_Job ID_** _7905_

**_\# Positions_** _1_

**_Category_** _Administrative/Clerical_