Fallon Health

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Claims Auditor

Claims Auditor

Job ID 
# Positions 
Posted Date 
Internal Audit

More information about this job


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 www.fallonhealth.org.


Brief Summary of purpose:

The Internal Audit Department (IA) at Fallon Health (FH) is designated Fraud, Waste and Abuse Unit for the company. As such, it’s our responsibility to provide guidance and oversight regarding preventive and detective activities. IA 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.


  • Conduct audits of claims payments for accuracy and compliance with existing policies and contracts.
  • Work with internal departments and external providers to correct system problems and recover overpayments.
  • Reports potential issues identified that relate to the Fallon’s Fraud and Abuse policy. This would include activities but not limited to billing for services that were not provided, intentional misrepresentation or the deliberate performance of unwarranted or medically unnecessary services for the purpose of financial gain.
  • Monitor dollar volumes of claims payments to providers on an ongoing basis.
  • Review new and re-newed provider contracts for appropriate payment requirements.
  • Assist in the test plan for selecting claims for review.
  • Collaborate with Claims, Contracts, and external providers to verify and resolve payment errors uncovered during reviews.
  • Investigate trends identified from claims analysis for fraud and abuse and/or inappropriate billing practices.
  • Develop recommendations to improve processes and strengthen internal controls surrounding contract loading and claim payment process.
  • Regularly report on the productivity to established performance metrics, report overall savings results and /or project goals.
  • Performs other duties as assigned.



Associates degree or equivalent in education and experience required.

Bachelor’s degree preferred or similar work experience



Certificate of Professional Coding, strongly preferred.



  • 3 - 5 years insurance industry experience, in-depth knowledge of contract loading and claims payment process
  • Claims auditing experience and decision making based on coding, analysis, problem solving and corrective action planning
  • Thorough knowledge of claims policy and procedures, and healthcare standards
  • Knowledge of finance/accounting, a plus.