Fallon Health

Manager

• Serve as the primary clinical liaison between Clinical Integration and IHCS
• Represent Clinical Integration in IHCS meetings, case conferences, and operational workgroups
• Review and triage complex IHCS referrals, service concerns, provider issues, and care coordination challenges
• Facilitate interdisciplinary case consultations for members with complex clinical, behavioral, or social needs
• Coordinate communication and follow-up between IHCS providers, care teams, and leadership
• Identify service barriers, trends, and systemic issues impacting IHCS members
• Develop recommendations to improve service delivery, communication, and member outcomes
• Monitor IHCS performance, service utilization, and operational effectiveness
• Serve as the organizational subject matter expert for the PCA Program and applicable MassHealth regulations
• Manage escalated PCA requests, concerns, service disputes, and operational challenges
• Lead Time-for-Task reviews and support clinical decision-making regarding PCA service needs
• Review complex PCA assessments and assist staff with PCA eligibility guidelines
• Consult on PCA eligibility determinations, service authorizations, appeals, denials, compliance requirements, and EVV processes
• Partner with LTSS, Utilization Management, and Medical Directors on complex PCA cases
• Collaborate with EVV stakeholders to identify barriers and develop solutions
• Monitor PCA approvals, appeals, service utilization, access barriers, and operational inefficiencies
• Lead consistency and standardization improvements for PCA-related processes
• Provide expert consultation to Nurse Case Managers, Assessment Nurses, Navigators, Supervisors, and Leadership
• Support member-centered care planning and service coordination
• Participate in case rounds, clinical reviews, quality initiatives, and operational meetings
• Escalate high-risk situations and ensure timely resolution
• Monitor program performance metrics and identify improvement opportunities
• Conduct IHCS and PCA process audits for compliance and consistency
• Analyze trends and recommend operational enhancements
• Assist with policies, procedures, workflows, and educational materials
• Participate in regulatory audit and program evaluation readiness activities
• Lead IHCS and PCA special projects and process improvement initiatives

Triage Case Manager

General

• Oversee the company’s EDI process, including tracking incoming and outgoing EDI files
• Monitor and research unsuccessful transmissions, recognize patterns, and contact appropriate parties to resolve issues
• Handle provider concerns regarding submission discrepancies
• Lead efforts to increase contracted provider use of electronic submission
• Train and develop EDI staff and other department members as needed
• Document new EDI procedures, policies, and processes
• Liaise with IT, Configuration, internal departments, external customers, and EDI Coordinators for day-to-day questions and issue resolution
• Implement HIPAA transaction sets across the company, including 270/271, 276/277, 278, 820, 835, 837I, and 837P
• Represent the EDI Team in meetings with internal and external customers
• Set up security for online tools, including Provider Tools and Employer Tools
• Run KEA scripting software for Weight Watchers claims
• Provide weekly updates on Trading Partners in testing phases
• Test Edifecs and QNXT system upgrades or changes related to electronic submission
• Test new and updated technology applications against current EDI logic and communicate results to appropriate departments
• Escalate and expand provider electronic claims submission to maximize Fallon Health’s EDI rate
• Increase the auto-adjudication rate of EDI claims according to annual strategic objectives
• Manage communications concerning submission issues requiring troubleshooting
• Administer relationships with clearinghouse vendors
• Track EDI file names, dates, claim counts, fatal edits, and file processing status
• Seek quality improvements for the EDI process
• Oversee and monitor claims reconciliation for EDI claim submissions

Triage Case Manager

Senior EDI Coordinator