Job Description

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:

The SIU Code Auditor will conduct coding audits of medical records provided by providers to check for missing documentation and other medical documentation for E&M, DME, medical, home health services, and may include some behavioral health care services to identify potential over-payments and suspected fraud waste and abuse. Serve as a clinical and code liaison for fraud, waste and abuse team while identifying areas of vulnerability and risk.

Responsibilities

Primary Job Responsibilities (include duties that represent 5% or more of employee's time)

The Internal Audit Department (IA) at Fallon Health serves as the company’s designated Special Investigation Unit (SIU) for fraud, waste, and abuse (FWA) activity. The department reports administratively to the Chief Compliance Officer and functionally to the Audit & Compliance Committee, and it plays a central role in detecting, reviewing, and addressing potential fraud, waste, and abuse.

In this role, the SIU Code Auditor is responsible for reviewing medical records, identifying coding and billing concerns, supporting investigations, and communicating findings and recommendations to internal and external stakeholders. This also includes tracking of cases assigned and maintaining documentation to department standards and assisting with reports due to both internal and external partners.

• Coding and audit review: Perform detailed reviews and audits of medical records to verify the accuracy of coding and charges for services provided. Review provider documentation and professional services using ICD-10, CPT, HCPCS, and applicable federal, state, local, payer, Medicare, Medicaid, LCD, NCD, and internal policy requirements.
• Investigative support: Review clinical and coding investigative summaries, including those prepared by external parties, to support findings of potential fraud, waste, or abuse. Provide feedback and recommendations to investigators and management.
• Pattern and risk identification: Identify aberrant billing patterns, trends, and indicators of fraud, waste, or abuse. Recommend providers for further review, conduct root cause analysis as needed, and suggest process or program improvements to leadership.
• Provider and stakeholder collaboration: Meet with providers to discuss audit findings and improvement opportunities. Work closely with clinical teams, coding teams, Medical Directors, external partners, and providers to support accurate billing and effective case resolution.
• Reporting, education, and regulatory support: Assist with claim denial reporting, respond to regulatory agency complaints, support required fraud reporting to state and federal agencies, and recommend to members, providers, or employee education based on findings.
• Case management and professional standards: Manage daily case review assignments with a strong emphasis on quality, provide regular updates to department leadership and senior management, maintain current knowledge of coding guidelines related to professional services, and perform other duties as assigned.
• Core work style expectations: Communicate effectively in writing and verbally, demonstrate strong listening skills, work independently, and consistently meet deadlines.
• Reports and Metrics: Communicate results to the team and help maintain and update key departmental reports and metrics.
• Administrative Functions: Perform administrative tasks that support daily operations, case tracking, documentation, and overall departmental workflow; including incoming and outgoing emails.

Qualifications

Education

Bachelor’s degree preferred or equivalent experience, and prior experience in healthcare

License/Certifications

Certified Professional Coder (CPC) and/or Certified Coding Specialist (CCS) is required. Clinical Experience is preferred.

Certified Evaluation and Management Coder (CEMC) or Certified Professional Medical Auditor (CPMA) are a plus.

Experience:

• 3-4 years of relevant experience.
• Demonstrated proficiency in medical record audits and analysis and ICD-10CM/CPT coding methodology, HCPCS Coding systems and guidelines and knowledge and understanding of medical terminology.
• Knowledge of billing and other coding edits, as well as Centers for Medicare and Medicaid Services (CMS) local and national coverage determinations, and managed billing regulations.
• Strong quantitative, analytical, interpersonal, written and communication skills
• Understanding in fraud, waste abuse regulations, or any combination of education and experience, which would provide an equivalent background

,,Pay Range Disclosure:In accordance with the Massachusetts Wage Transparency Act, the pay for this position is $87,500 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.

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