Claims Specialist - Health Insurance

Fallon Community Health Plan Worcester , MA 01601

Posted 1 week ago


Fallon Health Vaccination Requirements:

To protect the health and safety of our workforce, members and communities we serve, Fallon Health now requires all employees to disclose COVID-19 vaccination status. As of 2/1/2022 all roles not designated as "Remote" require full COVID-19 vaccination and Fallon Health will obtain the necessary information from candidates prior to employment to ensure compliance. Failure to meet the vaccination requirement may result in rescission of an employment offer or termination of employment.

About Fallon Health

Founded in 1977, Fallon Health is a leading health care services organization that supports the diverse and changing needs of those we serve. In addition to offering innovative health insurance solutions and a variety of Medicaid and Medicare products, we excel in creating unique health care programs and services that provide coordinated, integrated care for seniors and individuals with complex health needs. Fallon has consistently ranked among the nation's top health plans, and is accredited by the National Committee for Quality Assurance for its HMO, Medicare Advantage and Medicaid products. For more information, visit

Brief Summary of Position:

The Claims Specialist should have advanced claim processing knowledge at the highest complexity level. Knowledge of all Claim Specialist competencies plus added responsibility for adjusting claims, working provider and member cases, and resolving edits that fire on adjustments. Advanced understanding of authorizations, benefits, contracts, enrollments, fee schedules and Fallon Health's payment policies. Thorough knowledge of claims processing configuration and QNXT functionality. Ensures member and provider satisfaction by providing appropriate and timely processing of high complexity cases and adjustments (multi-step resolution). Monitors and resolves high volume of adjustments for all lines of business and ensures compliance with established guidelines. Must be able to work on tasks both independently and as part of a team.


  • Consistently meets or exceeds all department standards: productivity, quality, and attendance.

  • Accepts ownership and responsibility for resolving a high volume of adjustments for all lines of business.

  • Advanced knowledge of Fallon Health policies, protocols, and procedures.

  • Advanced understanding of authorizations, benefits, contracts, enrollments, and fee schedules.

  • Possess a firm understanding of Fallon Health's payment policies to accurately pay provider claims and eligible medical claims submitted for member reimbursement.

  • Resolves complex and high dollar adjustment requests, member and provider cases, and high volume adjustment projects.

  • Monitor and workdata integrity reports in accordance with department policies and procedures.

  • Ensures accuracy and timeliness of adjustment processing to minimize late payment interest penalties and ensures compliance with established payment and processing guidelines.

  • Prompt evaluation and resolution of Customer Service cases related to adjustment requests.

  • Demonstrates solid judgment and discretion working with confidential information.

  • Complies 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.

  • Demonstrates confidence by requiring minimal assistance from team subject matter experts (SME) to develop individual skills and grow professionally.

  • Works with teams inside and outside the department, and external customers as needed.

  • Demonstrates organizational, interpersonal, and communication skills.

  • The above is intended to describe the general content of the requirements for the performance of the job. It is not to be interpreted as an exhaustive statement of duties, responsibilities, or requirements.



High school diploma, college degree preferred. Medical billing and coding or equivalent experience preferred.


  • Minimum of 3 years health care industry experience or equivalent combination of education and experience.

  • Advanced knowledge of CPT, ICD-10, HCPCS coding guidelines and medical terminology preferred.

  • Demonstrated ability to accurately data enter and proficiently process high complexity claims.

  • Advanced understanding of all technical applications related to claim processing inc

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Claims Specialist - Health Insurance

Fallon Community Health Plan