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Fallon Health Medical Coder -Code Auditor- Growing Health Care Organization -HYBRID 2-3 days in office in Worcester, Massachusetts


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 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.

Hybrid Schedule 2-3 days in the office..


The Internal Audit Department (IA) at Fallon Health (FH) is the designated Fraud, Waste and Abuse (FWA) Unit for the company. FWA reports administratively to the Chief Compliance Officer and functionally to the Audit & Compliance Committee and plays a key role in employing various procedures to detect fraud, waste and abuse

  • In this role, the Code Auditor performs detailed reviews or audits of medical records to ensure accuracy of coding and charges for services This may include reviews of codes and professional services for accuracy performed by providers from medical records according to ICD-10, CPT, HCPCS, and provider documentation in compliance with accepted guidelines (federal, state, local, and insurance regulations as well as internal policies, as applicable, Medicare, Medicaid, and LCD (Local Coverage Determinations), and NCD (National Coverage Determinations).

  • Review clinical and code investigative summaries completed by external parties of audit findings of potential fraud, waste and abuse, and provide feedback to the investigator.

  • Identify aberrant billing patterns and trends, evidence of fraud, waste or abuse, and recommend providers to be flagged for This may involve further reviews into inappropriate billing practices or root cause analysis for issues and recommend changes to the FWA Director.

  • Help to mitigate FWA globally by providing feedback to management related to trends and

  • Review clinical and code investigative summaries to support findings of potential fraud, waste and abuse, and provide recommendations to the

  • Assist in the review of clinical trials and make recommendations to

  • Assists with claim denial reports to ensure optimal

  • Meets with the providers to review the audit findings and to recommend ways to improve when indicated

  • Work closely with other clinical and coder teams as well as Medical Directors; including external partners and

  • Assist in responding to various regulatory agency complaints and assist in the filing of, fraud reports as required by state and federal

  • Maintain and manage daily case review assignments, with a high emphasis on quality and presents regular updates to Director of the department and upper management.

  • Make recommendations for member/provider/employee education related to the

  • Performs other duties as

  • Ability to communicate effectively both verbally and in writing strong listening skills, can work independently and ability to meet

  • Responsible for maintaining up to date knowledge of coding guidelines as they relate to professional services



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


  • 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.


  • 3-4 years of relevant experience

  • Demonstrated proficiency in medical record analysis and ICD-10CM/CPT coding methodology 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 care billing regulations.

  • Strong quantitative, analytical, interpersonal, written and communication skills

  • 1 year in fraud, waste abuse experience; or any combination of education and experience, which would provide an equivalent background is considered a plus.

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.

Fallon Health Vaccination Requirements:

To protect the health and safety of our workforce, members and communities we serve, Fallon Health now requires all employees to disclose COVID-19 vaccination status. As of 2/1/2022 all roles not designated as “Remote” require full COVID-19 vaccination and Fallon Health will obtain the necessary information from candidates prior to employment to ensure compliance. Failure to meet the vaccination requirement may result in rescission of an employment offer or termination of employment.


Location US-MA-Worcester

Posted Date 2 months ago (8/9/2023 2:43 PM)

Job ID 7381

# Positions 1

Category Internal Audit