Job details

Provider Specialist

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Overview

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 (Program of All-Inclusive Care for the Elderly)— in the region. Learn more at fallonhealth.org or follow us on Facebook, Twitter and LinkedIn.

Brief Summary of purpose:

Respond to physician, hospital, ancillary provider inquiries and requests for services associated with the resolution of provider complaints relating to operational concerns, policy and procedures for Fallon Health products and subsidiaries. Understand Fallon Health policies and facilitate and the research required to resolve provider issues. Work collaboratively with internal departments to resolve provider items and look for process improvements. Validate and Update provider demographic and practice changes applicable to the assigned provider territory. Update provider demographic and non contractual changes in QNXT/eVips accurately and timely.

Responsibilities

Primary Job Responsibilities:

Receive daily calls and email correspondence from assigned physicians, hospitals, and ancillary providers requesting information and services.
Act as primary point of contact with assigned providers by promoting a one-stop customer service for escalated provider service issues. Escalations come from internal departments and external provider contacts.
Utilize appropriate internal resources in order to analyze and resolve issues.
Monitor status of QNXT cases thru to resolution status. Maintain detailed documentation within QNXT cases. Conduct proactive follow-up activities with provider and/or Fallon Health staff.
Validate data received by providers and update demographic and practice changes at the request of the assigned provider.
Adhere to departmental, corporate standards and policy and procedure (i.e., Fallon Health Service Level agreements) issue resolution timeframes, PUNKS, QNXT case inventory/assignments, etc.)
Assist and support the Provider Relations Representative on Provider enrollment initiatives.
Escalate critical issues and conflicts to Manager, Provider Data or Sr. Director, Benefit and Provider Configuration as appropriate.
Maintains assignments related to assigned territory, [i.e., internal Joint Operations Committee meetings, provider contract knowledge, PCP reports (changes, additions, deletions)], as appropriate.
Participate in external and internal provider meetings for assigned provider territory on a schedule or dependent upon urgency identified by Manager.
Manage all Provider Adds/Updates in the eVIPS application
Process any Group/Facility needs as identified by the Contracting Team in the eVIPS application

Qualifications

Education:

Bachelor’s degree or equivalent combination of training and experience

Experience:

2 years’ experience in a customer service role for a healthcare services organization
Proficiency with desktop computer applications, Microsoft Office package, mainframe knowledge (QNXT/eVips)
Knowledge of medical terminology/claims payment, ICD and CPT coding familiarity
Exemplary customer relations expertise
Clear concise written and verbal communication skills
Ability to manage, organize, document and prioritize multiple tasks simultaneously

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.

Fallon Health Glassdoor Company Review

3.7

Fallon Health DE&I Review

No rating

CEO of Fallon Health

Richard Burke

Approve of CEO

Average salary estimate

$55000 / YEARLY (est.)

min

max

$50000K

$60000K

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What You Should Know About Provider Specialist, Fallon Health

Are you ready to take your career to the next level with a mission-driven company? Fallon Health is on the lookout for a Provider Specialist to join our passionate team in Worcester. At Fallon Health, we prioritize our members by ensuring they receive the care they deserve. As a Provider Specialist, you will be the key point of contact for physicians, hospitals, and other ancillary providers, addressing their inquiries and resolving operational concerns. This isn't just about answering calls; it’s about fostering strong relationships and consistently improving the services we provide. You’ll be responsible for facilitating efficient communication, handling requests for service resolution, and conducting proactive follow-ups to ensure all issues are resolved satisfactorily. Your analytical skills will come in handy as you identify and enhance our processes while accurately updating provider demographics in our systems. With a focus on teamwork, you'll collaborate with various departments and help manage the flow of information related to provider issues. We're looking for someone with a customer service background in the healthcare realm, superb communication skills, and the ability to juggle various tasks. If you are eager to contribute to Fallon Health's mission of improving health and inspiring hope, while growing in a supportive environment, then this Provider Specialist role is for you. We value diversity and integrity, embracing all unique capabilities to better serve our members. Come grow with us!

Frequently Asked Questions (FAQs) for Provider Specialist Role at Fallon Health

What are the responsibilities of a Provider Specialist at Fallon Health?

As a Provider Specialist at Fallon Health, your main responsibilities include responding to inquiries from physicians and hospitals, resolving provider complaints, and managing service requests. You'll act as a primary point of contact for assigned providers, analyze issues using internal resources, and ensure thorough documentation within our systems. Additionally, you will be involved in updating provider demographics and facilitating communication between providers and internal departments.