Job Information
Fallon Health Provider Data Reviewer - 3 days/week in Worcester office in Worcester, Massachusetts
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:
Under the general supervision of the Manager of Configuration Audit and Directories, staff will perform an audit sampling of provider data within the symplr Payer application. Completes a score form in a Microsoft Access tool, prepares audit summaries, and sign off forms for staff and managers. Identifies trends in errors and recommends improved processes and/or training needs. Meets with Provider Specialist staff monthly to review error trends and collaborate solutions for issues related to provider data.
Responsibilities
Primary Job Responsibilities
• Reviews configuration of providers in the symplr Payer (eVIPs) application for accuracy
• Organizes and prioritizes workload to meet audit timeframes.
• Provides audit scoring results to management and staff.
• Identifies and documents errors and trends for monthly metrics.
• May provide assistance with training based on system modifications and or new processes.
• Works independently but also is supportive of the team goals.
• Serve as a subject matter expert and provide peer support in a mentoring or collaborative capacity in the office environment, whether it be training or answering of questions, as deemed appropriate by management.
• Provides support in auditing provider linking to contract logic in QNXT; completing 10 records monthly to maintain provider linking knowledge.
• May review P&Ps for updates needed and provide updates to management for review.
Qualifications
Education
Bachelor’s degree preferred and/or similar work experience
Experience
Minimum of 3 years’ experience in health care is required and 2-3 years in an auditing or analytical related field is preferred. Proficiency in Microsoft Office tools: Excel, Word, Access; including experience in comparing documents. Knowledge of provider data/enrollment. Experience in the symplr Payer (eVIPs) and QNXT systems is preferred but not required.
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.
#P02
Location US-MA-Worcester
Posted Date 1 week ago (3/3/2025 10:14 AM)
Job ID 7861
# Positions 1
Category Provider Relations