Member Intake Admin - Flex

Overview

Member Intake Admin - Flex schedule after 90 days - $22/hr

Location:

US-MA-Worcester

Job  
• Positions: 1
• Category:
Administrative/Clerical

Fallon Health is a company that cares. We prioritize our members—always making sure they get the care they need and deserve. 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 embrace differences and strive to be inclusive in all aspects of our work.

Fallon Health (FH) Appeals and Grievance process is an essential function to FH's compliance with CMS regulations, NCQA standards, other regulatory requirements and member expectations. The FH Member Appeals and Grievances 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 triages and assigns all incoming appeals and grievances addressed to the Member Appeals & Grievances Department and provides administrative support to the department.

• Administer FH Standard and Expedited Appeals Processes as outlined in Member Handbook/Evidence of Coverage for all products, in compliance with applicable NCQA standards and other regulatory requirements. Strict adherence to department turn-around time standards.
• Act as the initial investigator and contact person for member grievances and appeals, including acknowledgement, education, and gathering pertinent information from the member.
• Print, mail, and triage letters at the FH corporate office (10 Chestnut Street, Worcester, MA).
• Identify the need for Personal Representative Authorization form, Medical Record Release Authorization form, or Provider Payment Waiver form and request necessary documentation.
• Assign case files to department staff for case management.
• Manage incoming faxes and member-specific data, routing to appropriate staff.
• Produce, maintain, and distribute reports/calendars to assist in workload planning.
• Process department incoming/outgoing mail per established workflows in a timely and accurate manner.
• Provide administrative/clerical support, including acquisition of medical records from providers.
• Retrieve messages from email and voicemail, routing to appropriate staff.
• Photocopy and compilation of appeal case files when necessary.
• Complete requests for additional information from external review agencies.
• Perform additional clerical/administrative responsibilities as directed by the Director or Manager.
• Provide administrative assistance in support of the Board of Hearings (BOH) process, including preparation of hearing packets, reviewing materials, and tracking decisions.
• Ensure all grievances/appeals are processed in adherence to state and federal regulations (CMS, Mass Health, OPP), contractual obligations, NCQA guidelines and FH policy.

• 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)

Pay Range Disclosure:
In accordance with the Massachusetts Wage Transparency Act, the pay range for this position is $21 - $22/hour. Final compensation will depend on experience and fit with the role’s responsibilities.

Fallon Health provides equal employment opportunities to all employees and applicants and prohibits discrimination and harassment of any type.

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