Member Appeals & Grievances Triage Admin - Worcester office based

Location

Worcester, MA

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—in the region. Learn more  or follow us on Facebook, Twitter, and Linked In.

Brief summary of purpose: The Fallon's Appeals and Grievances process is essential for compliance with CMS regulations, CMS 5 Stars, NCQA standards, other applicable regulatory requirements, and member and provider expectations. The Appeals and Grievances Triage Administrator administers the process as outlined in the FH Member Handbook/Evidence of Coverage, departmental policies and procedures, and regulatory standards. The Triage Administrator triages and assigns all incoming appeals and grievances addressed to the Member Appeals & Grievances Department and Provider Appeals Department.

This position also provides administrative support to the departments and serves as liaison between Fallon Health members and contracted providers regarding appeals and grievances.

• Act as the initial investigator and contact person for grievances and appeals, which includes sending the appropriate acknowledgement of the grievance/appeal, educating members, and gathering all pertinent information.
• Act 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.
• Process all incoming mail and forward initial claim submissions, claim adjustments, and other miscellaneous mail to appropriate departments; manage incoming faxes, emails, voicemails and member/provider specific data, routing to the appropriate staff member.
• Identify the need for Personal Representative Authorization form, Medical Record Release Authorization form, or Provider Payment Waiver form and request such documentation as necessary.
• Assign case files to the department staff for appeal/grievance management.
• Provide administrative assistance in support of the Board of Hearings (BOH) process, including preparation of hearing packets, reviewing of materials, and tracking and monitoring hearing decisions.
• Ensure that all grievances/appeals are processed in adherence to state and federal regulations (i.e., CMS, Mass Health, OPP), contractual obligations, NCQA guidelines and FH policy.
• Process reports which produce all correspondence to providers related to appeal determinations and untimely requests, and send that correspondence to providers.
• File individual provider appeal 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 or GED required.

License/Certification: Reliable transportation required.

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

Pay Range Disclosure: In accordance with the Massachusetts Wage Transparency Act, the pay range for this position is $21–$22/hour, which reflects what we reasonably and in good faith expect to pay at the time of posting. Final compensation will depend on the candidate’s experience, skills, and fit with the role’s responsibilities.

Equal Employment Opportunity Statement: 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.