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Fallon Health Coding and Documentation Integrity Specialist - Remote Opportunity in Worcester, Massachusetts


About Fallon Health

Founded in 1977, Fallon Health is a leading health care services organization that supports the diverse and changing needs of those we serve. In addition to offering innovative health insurance solutions and a variety of Medicaid and Medicare products, we excel in creating unique health care programs and services that provide coordinated, integrated care for seniors and individuals with complex health needs. Fallon has consistently ranked among the nation’s top health plans, and is accredited by the National Committee for Quality Assurance for its HMO, Medicare Advantage and Medicaid products. For more information, visit fallonhealth.org.

Brief Summary:

The Coding and Documentation Integrity Specialists II’s primary responsibility is to support the provider appeals department. The Coding and Documentation Integrity Specialists II’s job will focus on coding and documentation support for provider appeals department, assisting with E/M audits. The Coding and Documentation Integrity Specialist II will review medical record details and documentation observations from multiple chart sources to validate E/M level of service, medical necessity and payer policy guidelines. The Coding and Documentation Specialist II must demonstrate the ability to work with the Coding and Documentation Integrity team effectively and efficiently. Light travel involved


Chart/Claim Reviews

  • Perform medical record chart reviews for designated populations & volumes

  • Validate E/M level of service, medical necessity and payer policy guidelines

  • Own medical record chart review process from start to end including auditing for E/M, Medical Decision Making, validating CPT procedures, make recommendation for provider appeals medical director

  • Prepare formal documentation for physician review

  • Assist with provider appeals coding and documentation education

Regulatory compliance

  • Develop and present concise provider-specific feedback for targeted providers and provider groups.

  • Identify approriate levels of E/M, coding and documentation support in support of claims adjustment efforts

  • Ensure medical record chart reviews and related claims adjustment activities completed within regulatory datasubmission timelines and within CMS Coding and Coding Clinic guidelines

Corporate project support

  • Participate in corporate projects and subgroup meetings. Complete analyses related to corporate projects and business needs as needed.

  • Participate in regional Coding Chapter meetings



High School diploma or GED required. Bachelor degree preferred


  • CPC, CEMC/CPMA is required


  • E/M coding, provider appeals, CPT coding, HCPCS coding, medical record auditing, billing, claims processing, medical record review, medical record abstract or combination- minimum of 5-7 years experience

  • Medical billing/claims processing, medical record auditing, medical record review, medical record abstraction or combination

  • Ability to assess Regulatory changes and determine, implement and communicate appropriate course of action

  • Ability to asses ongoing monitoring of State and Federal Notices across multiple LOBs, determine, implement and communicate appropriate course of action

  • Ensure Regulatory changes are implemented within appropriate Fallon Health Policies and internal departments are notified

  • Ability to perform analysis and reporting

  • Strong understanding of Medical terminology

  • Strong CMS, CPT, ICD-10-CM coding guidelines and conventions

  • Microsoft Excel-intermediate skill set

  • Microsoft Access-intermediate skill set

  • Evaluate Provider Appeals related to coding guidelines and make an Appeal determination taking into consideration FH’s existing business rules and vendor processes

  • Ability to understand, evaluate and communicate Payer Payment policy guidelines

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.


Location US-MA-Worcester

Posted Date 3 weeks ago (4/14/2021 4:22 PM)

Job ID 6327

# Positions 1

Category Claims Administration