Job Description

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.

This position requires permanent work authorization in the U.S. We will not provide visa sponsorship or accept candidates on OPT/CPT for this role.

We can only hire from the Following states for this position:

• MA, CT, RI, NH, NY (not Burroughs)
• FL, GA, TX, NJ
• ME, VT

Brief summary of purpose

The Information Management Analyst III, Encounter Reporting & Risk Adjustment Support is responsible for leading the analysis, validation, reconciliation, and submission of healthcare encounter data to the Commonwealth of Massachusetts and other regulatory entities. This role serves as a subject matter expert in encounter reporting and collaborates closely with the Risk Adjustment Department to ensure the completeness, accuracy, and integrity of data used for reimbursement, regulatory compliance, and quality reporting.

The position works cross-functionally with Claims, Enrollment, Provider Operations, Information Technology, Compliance, and Risk Adjustment teams to identify data quality issues, investigate reporting discrepancies, and implement process improvements. The individual will also provide mentorship, project leadership, and operational guidance to support succession planning for a future leadership role within the Encounter Reporting function.

Responsibilities

Primary Job Responsibilities

• Monitor encounter submission performance, acknowledgments, rejections, and acceptance rates.
• Analyze and resolve encounter data errors and submission failures.
• Ensure compliance with Massachusetts reporting requirements, submission specifications, and reporting deadlines.
• Coordinate testing and validation activities for system implementations affecting encounter data.
• Partner with the Risk Adjustment team to support diagnosis and encounter data accuracy.
• Assist in identifying gaps in encounter submissions that may impact risk score accuracy.
• Support CMS and internal audit activities related to diagnosis and encounter data validation.
• Act as liaison between business teams, IT departments, vendors, and external agencies.
• Translate business and regulatory requirements into reporting and technical specifications.
• Lead issue resolution meetings involving encounter reporting and data quality concerns.
• Participate in enterprise initiatives impacting healthcare data management and reporting processes.
• Build leadership skills through project leadership and stakeholder management responsibilities.
• Mentor junior analysts and new team members.
• Review work products and provide quality assurance guidance.
• Assist with prioritization of team workload and reporting schedules.
• Lead special projects and continuous improvement initiatives.
• Provide subject matter expertise during audits, implementations, and strategic initiatives
• Analysis and support of the Interoperability data streams.

Qualifications

Qualification requirements Education: College degree in computer science, engineering, management information systems or related discipline. Other degrees will be considered with appropriate background and experience

License/Certifications

N/A

Experience

• 5+ years of healthcare data analytics, encounter reporting, claims reporting, or regulatory reporting experience.
• 5+ years applied technical skills related to SQL, data analytics, data warehousing techniques, visualization tools, project management, requirements elicitation.
• 5+ years’ experience providing application support or configuration of relevant healthcare / health insurance applications.

Pay Range Disclosure:In accordance with the Massachusetts Wage Transparency Act, the pay for this position is $ 125, 000 - $ 130,000 annually which reflects what we reasonably and in good faith expect to pay at the time of posting. Final compensation will depend on the candidate’s experience, skills, and fit with the role’s responsibilities.

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.

#P01