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Fallon Health Provider Relations Representative - Growing Healthcare Organization in Worcester, Massachusetts


About Fallon Health:

Fallon Health is a mission-driven not-for-profit health care services organization based in Worcester, Massachusetts. For 45 years we have been improving health and inspiring hope in the communities we serve. Committed to caring for those who need us most, we pride ourselves on providing equitable access to coordinated, integrated care for our members with a special focus on those who qualify for Medicare and Medicaid. We also serve as a provider of care through our Program of All-Inclusive Care for the Elderly (PACE). Dedicated to delivering high quality health care, we are continually rated among the nation’s top health plans for member experience and service and clinical quality.

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.


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.



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


Valid Driver’s License and Clean Driving Record Required


  • 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.

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 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.


Location US-MA-Worcester

Posted Date 2 weeks ago (1/24/2023 3:33 PM)

Job ID 7174

# Positions 1

Category Network Development