Member Appeal & Grievances Triage Administrator

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:

Fallon Health (FH) Appeals and Grievance process is an essential function to FH's compliance with CMS regulations, CMS 5 Stars, NCQA standards, other applicable regulatory requirements and member and provider expectations. The FH Appeals and Grievances Triage 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 Triage Administrator is responsible for triaging and assigning all incoming appeals and grievances addressed to the Member Appeals & Grievances Department and Provider Appeals Department. This position will also provide administrative support to the departments. Serves as liaison between Fallon Health members and contracted providers regarding appeals and grievances.

This position is divided equally between Member Appeals and Grievances Department and Provider Appeals Department with 20 hours dedicated to each department per week.
• Act as the initial investigator and contact person for 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.
• Acts as the initial investigator for provider appeals related to filing limit, claim denials, claim payment, retrospective referrals, administrative inpatient days and other issues for which the provider is liable.
• Responsible for processing all incoming mail, as well as forwarding all initial claim submissions, claim adjustments, and other miscellaneous mail to appropriate departments. Managing incoming faxes, emails, voicemails and member/provider specific data, routing to the appropriate staff member.
• 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 appeal/grievance management.
• 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.
• Processing of reports which produce all correspondence to providers related to appeal determinations and untimely requests, as well as sending those correspondence to providers.
• Filing of individual provider appeals files in accordance with department standards. Maintain provider appeal database and analyze data to assist provider appeal coordinators in production of monthly reports forwarded to management.
• Print and mail letters at the FH corporate office located at 1 Mercantile Street, Worcester, MA several times per month or as needed, as designated through a rotational in-office calendar or at the direction of a supervisor or manager.

Education

High School Diploma

License/Certification

Reliable Transportation required

Experience

Minimum 2 years' experience in the operational side of a healthcare or insurance organization preferred.

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.