Fallon Health is a health plan focused on coordinated care, government-sponsored health insurance programs, and improving health outcomes for its members.
The SIU Code Auditor conducts coding audits of medical records to identify missing documentation, coding and billing issues, potential overpayments, and suspected fraud, waste, and abuse. The role also serves as a clinical and coding liaison for the fraud, waste, and abuse team while identifying areas of vulnerability and risk.
Responsibilities include:
- Performing detailed reviews and audits of medical records to verify the accuracy of coding and charges for services provided
- Reviewing provider documentation and professional services using ICD-10, CPT, HCPCS, and applicable federal, state, local, payer, Medicare, Medicaid, LCD, NCD, and internal policy requirements
- Reviewing clinical and coding investigative summaries to support findings of potential fraud, waste, or abuse
- Identifying aberrant billing patterns, trends, and indicators of fraud, waste, or abuse
- Meeting with providers to discuss audit findings and improvement opportunities
- Supporting claim denial reporting, regulatory agency complaints, and required fraud reporting to state and federal agencies
- Managing daily case review assignments and maintaining documentation, reports, and metrics
- Performing administrative tasks that support daily operations, case tracking, and departmental workflow
Bachelor’s degree preferred or equivalent healthcare experience.
Required certifications:
- Certified Professional Coder (CPC) and/or Certified Coding Specialist (CCS)
Preferred certifications:
- Certified Evaluation and Management Coder (CEMC)
- Certified Professional Medical Auditor (CPMA)
Experience and skills:
- 3-4 years of relevant experience
- Proficiency in medical record audits and analysis
- Strong knowledge of ICD-10-CM, CPT, HCPCS, medical terminology, and coding methodology
- Knowledge of billing edits, CMS local and national coverage determinations, and managed billing regulations
- Strong quantitative, analytical, interpersonal, written, and verbal communication skills
- Understanding of fraud, waste, and abuse regulations
Location
Massachusetts, US
Employment Type
Full-time
Experience Level
Intermediate Level
Salary Range
$87,500 - $87,500
Remote work allowed
Yes
Posted
1 month ago