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Fallon Health · 12 hours ago

Claims Examiner

US-MA-Worcester

Full-time

Hybrid

Entry, Mid Level

2+ years exp

Fallon Health is a company that prioritizes member care and delivers high-quality, coordinated health services. The Claims Examiner role involves processing claims, ensuring member and provider satisfaction, and resolving complex claims efficiently while adhering to company guidelines.

FitnessHealth CareMedical

H1B Sponsor Likely

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 requirements for the performance of the job. It is not to be construed as an exhaustive statement of duties, responsibilities or requirements

Qualification

Claims processing knowledgeCPT codingICD-10 codingHCPCS codingMedical terminologyMS OfficeAnalytical abilityProblem solvingResults oriented

Required

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

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

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

Work with teams inside and outside the department, and external customers as needed

Minimum of 2 years health care industry experience or equivalent

Solid working knowledge of claim processing from all perspectives (submissions, processing, dependencies)

MS Office and general PC skills

Analytical ability – Gathers relevant information systematically. Considers a full range of issues or factors. Grasp complexities and perceives relationships 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 consistently one of the top performers. Steadfastly pushes self for results

Preferred

High school diploma, college degree preferred

Medical billing and coding or equivalent experience preferred

Solid working knowledge of CPT, ICD-10, HCPCS coding guidelines and medical terminology 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)