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Fallon Health Director Claims Compliance & Payment Integrity - Hybrid Remote in Worcester, Massachusetts


The Claims Director will be responsible for Claims Compliance (i.e., MAR, SOC, CMS, State and Federal regulations), Quality of Claims processing and development of a sophisticated Payment Integrity program within the claims organization. This role will also play an active role in the establishment of the organization, working closely with project teams responsible for the development and continued enhancement of the claims processing technical platform.


  • Develop and staff a sophisticated Payment Integrity program (from the foundation, to analytics and metric reporting

  • Propose initiatives that support the strategic objectives of the larger organization, identifying short and longer-term requirements for cost avoidance opportunities, inclusive of feasibility and return on investment.

  • Conduct/Oversee studies or analysis to determine feasibility and costs of initiatives.

  • Perform review of federal and state regulatory changes, identify changes needed to current business practice and implement/validate (i.e., CMS Universes for CMS audits)

  • Lead all claims audits from review of requirements, articulating business changes and performing validation

  • Determine long-term resources (systems, skills needed, capacity planning, etc.) to meet future business needs.

  • Participate in cost/benefit analysis of operational changes in support of future business requirements.

  • Regularly track group/departmental costs, ensuring these are managed within budget. Employ cost containment measures while retaining quality and efficient operations and a productive, healthy work environment. Anticipate expenses and identify potential budgetary concerns to VP of Claims and Configuration.

  • Regularly analyze and report on the productivity and effectiveness of the operations in comparison to established performance metrics. Identify areas of improvement and recommend resolution.

  • Work cross-functionally to ensure operations and changes are well integrated.

  • Proactively seek feedback from other groups on the impact and effectiveness of current and changes to operations.

  • Implement, manage and refine business processes required to deliver expected business results.

  • Implement short-term staffing plans to ensure anticipated operational requirements are met. Monitor the workload and adjust staff assignments accordingly.

  • Ensure team has appropriate resources and highlights areas of need to Vice President for resolution.

  • Ensure the timely and accurate exchange of information/data with relevant stakeholders of the operation.

  • Monitor the work environment and the business operation. Address concerns that may affect the morale and/or operational effectiveness of the group.

  • Ensure objectives defined across a broader group are integrated and supportive where necessary.

  • Define roles and accountabilities for staff, within the group and in the context of the broader process/operation in support of cross-functional efforts.

  • Hire for, develop and recognize the experience and knowledge/skills/abilities required for a successful team.

  • Provide for the orientation and welcome of new staff.

  • Define performance expectations and goals for staff.

  • Conduct routine performance touch point meeting.

  • Train and mentor staff on the application of policy and procedures, use of supporting systems/applications, appropriate soft skills: time management, etc.

  • Monitor work of individual staff for efficiency, effectiveness and quality. Provide ongoing constructive feedback and guidance to staff. If needed, conduct performance management in adherence with company policies.

  • Evaluate staff on achievement of goals and deliverables and assessment of competencies. Help staff progress in their careers to the benefit of the department and broader organization. Manage the resolution of performance issues in consultation with Human Resources as appropriate.

  • Proactively communicate with other departments to ensure cross-functional concerns are identified and effectively addressed.

  • Establish and maintain an open communication channel with staff.

  • Monitor effectiveness of communication with other groups (internal and external). Collaborates with Vice President to implement changes as necessary to ensure an open, productive exchange of information.

  • Represent the department as requested.

  • Ensure relevant changes to operations and/or contractual requirements can be supported.

  • Ensure operational compliance with all relevant regulatory agencies such as CMS, State of Massachusetts, internal controls such as MAR or SOC controls

  • Ensure department and vendors are meeting/exceeding contractual and business requirements.

  • Keep abreast of changes in State and Federal requirements and ensure they are implemented in a timely fashion.

  • Proactively identify areas of concern or exceptions and promptly evaluate root cause and mitigation strategies and notification to impacted stakeholders

  • Serve as a subject matter expert and provide peer support in a mentoring or collaborative capacity in the office environment, whether it be training or answering of questions, as deemed appropriate by management.


  • Bachelor degree in business or other applicable field. Master’s degree in business or other applicable field preferred but not required

  • 10 + years of claims and health care administration and/or managed care experience with Director level experience.

  • Strong claims knowledge of health insurance industry with all Regulatory lines of business (Medicare, Medicaid, PACE, Duals, FHW, etc.)

  • Proven experience launching and driving a robust Payment Integrity Program (inclusive of editing, oversight and implantation of future edits/regulations related to Claims Payment Pricing Vendors, vended programs, such as DRG validation, Hospital Bill Audit, High Dollar Claims review, etc.) resulting in significant cost avoidance on an annual basis.

  • Extensive knowledge of claims policies and procedures, including regulatory requirements and industry standards from AMA, CMS and CCI Edits.

  • Strong Analytical Ability and Data Mining abilities in order to identify organizational payment integrity opportunities

  • Extensive knowledge of federal and state regulations, legislation and laws, auditing reports and system functions; comparing functions with established standards and leading CMS audits

  • Strong vendor management

  • Experience in forecasting.

  • Expertise in root cause analysis and impact assessments with the goal of mitigation and/or process improvements.


Location US-MA-Worcester

Posted Date 2 weeks ago (11/19/2021 4:31 PM)

Job ID 6608

# Positions 1

Category Claims Administration