Provider Relations Representative - Fallon Health

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: 

Serve as primary liaison between FCHP and all contracted and limited non-contracted physicians/providers, hospitals, and ancillary providers within an assigned territory.  Monitor provider business operations to ensure compliance with FCHP's documented standards, policy and procedures and government regulations.

Primary Job Responsibilities: 

• Serve as primary Fallon Health contact for providers to resolve issues relating to the administration and operation of providers' contracted services.
• Orient and educate primary care, specialist, hospital, and ancillary providers by conducting physician and office staff visits.  Educate providers on Fallon Health policies and procedures to include products, benefits, claims, referral and eligibility verification processes, utilization management guidelines, etc.  Activities include conducting both individual and large group education sessions on a continual basis.
• Engage necessary Fallon Health staff members and conduct investigative research to resolve provider issues. Work collaboratively with internal partners to reduce provider issues and implement long term solutions to problems identified.
• Escalate conflicts to Manager of Provider Relations and when appropriate Director, Provider Relations.
• Monitor and counsel providers on disciplinary actions and non-compliance issues.
• Develop and maintain positive and productive rapport with Fallon Health providers through proactive relationship management and communications.
• Assist in the development of provider training material and provider tools. Deliver provider training including new provider orientations, individual and/or group training on various healthcare administration topics, government compliance regulations and FCHP policies and procedures for products, benefits, claims, referral, and eligibility and utilization management.
• Co-lead internal and external Joint Operations Committee meetings with contract managers.
• 30-50% Travel is required.

Education:

• Bachelor's degree in related discipline with healthcare administration training highly desirable

License/Certifications:

• Valid Driver’s License and Clean Driving Record Required

Experience: 

• 3-5 years’ experience
• Thorough knowledge of government regulations as dictated by regulatory agencies, including NCQA (National Committee on Quality Assurance) and CMS (Centers for Medicare & Medicaid Services).
• Proficiency with desktop computer applications, Microsoft Office package and Mainframe knowledge (i.e. QNXT, IDX etc.)
• Training curriculum development and platform presentation techniques.
•  Exemplary customer relations skills.
• Clear and concise written and verbal communication skills.

COVID-19 Vaccination:

With the end of the Global Coronavirus COVID-19 Pandemic, Fallon Health no longer requires all employees to be vaccinated against COVID-19 except for employees who are in jobs that under state and federal laws, regulations and policies are required to be vaccinated and/or they are in Member/participant facing positions.

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.