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Fallon Health · 2 months ago

Member Appeal & Grievances Triage Administrator

US-MA-Worcester

Full-time

Onsite

Entry Level

2+ years exp

Fallon Health is a healthcare company focused on delivering high-quality, coordinated care to its members. The Member Appeal & Grievances Triage Administrator is responsible for managing the appeals and grievances process, ensuring compliance with regulations and providing administrative support to the relevant departments.

FitnessHealth CareMedical

H1B Sponsor Likely

Responsibilities

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

Qualification

Healthcare operations experienceGrievance handlingAppeals processingAdministrative supportCommunication skillsOrganizational skills

Required

High School Diploma

Reliable Transportation required

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

Company

Fallon Health

Founded in 1977, Fallon Health is a community-focused not-for-profit health care services organization based in Worcester, Massachusetts.

Founded in 1977

Worcester, Massachusetts, USA

1001-5000 employees

http://www.fchp.org

H1B Sponsorship

Fallon Health has a track record of offering H1B sponsorships. Please note that this does not guarantee sponsorship for this specific role. Below presents additional info for your reference. (Data Powered by US Department of Labor)

Distribution of Different Job Fields Receiving Sponsorship

Represents job field similar to this job

Trends of Total Sponsorships

2025 (8)

2024 (8)

2023 (5)

2022 (9)

2021 (7)

2020 (5)