Claims Examiner - Fallon Health

The Claims Examiner position is a hybrid role working 3 days (Tuesdays, Wednesdays and Thursdays) in the office in Worcester, MA and 2 days working at home.  

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 of purpose: 

The Claims Examiner should have thorough claim processing knowledge at a complex level.. Thorough understanding of authorizations, benefits, contracts, enrollment and fee schedules.  Ensures member and provider satisfaction by providing appropriate and timely processing of involved cases and claims (multi-step resolution).  Monitors and resolves high volume of claims for all lines of business, as well as high dollar claims, to minimize late payment interest penalties and ensure compliance with established guidelines. Must be able to work on tasks both independently and as part of a team.

Primary Job Responsibilities: 

• Meets or exceeds all department standards: productivity; quality; and attendance.
• Responsible for resolving a high volume of claims edits for all lines of business.
• Thorough knowledge of Fallon Health policies and procedures.
• Thorough understanding of authorizations, benefits, contracts, enrollment and fee schedules.
• Price claims using external vendor processing systems and manually apply rates in the core system.
• Resolution of complex and high dollar claims.
• Ensures accuracy and timeliness of claims processing to minimize late payment interest penalties and ensure compliance with established guidelines.
• Evaluation and resolution of Customer Service cases related to pended claims.
• Demonstrate solid judgment and discretion working with confidential information.
• Comply with all department and company guidelines including all applicable laws and regulations.
• Demonstrates ability to perform independently in conformance with written instructions, established timeframes, and pre-determined priorities.
• Seeks intermittent assistance from Team Subject Matter Experts (SMEs), the Trainer and Claims Manager to ensure accuracy of adjudicating claims and to develop individual skills and grow professionally. 
• Work with teams inside and outside the department, and external customers as needed.
• The above is intended to describe the general content of the requirments for the performance of the job.  It is not to be construed as an exhaustive statement of duties, responsibilities or requirements

Education:

High school diploma, college degree preferred. Medical billing and coding or equivalent experience preferred.

Experience: 

• Minimum of 2 years health care industry experience or equivalent
• Solid working knowledge of CPT, ICD-10, HCPCS coding guidelines and medical terminology preferred. 
• Demonstrated ability to enter and process medium complexity claims efficiently and in a quality manner.
• Solid working knowledge of claim processing from all perspectives (submissions, processing, dependencies)
• MS Office and general PC skills.
• 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 medium 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 successfully.  Is consistantly one of the top performers.  Steadfastly pushes self for results.     

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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