Fallon Health

  • Medical Coding Quality Reviewer/Educator- Growing Healthcare Organization - CPC ,CCS or CRC required.

    Location US-MA-Worcester
    Posted Date 3 months ago(1/9/2018 11:24 AM)
    Job ID
    # Positions
    Risk Adjustment
  • Overview

    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 of Purpose:

    Responsible for the overall improvement of the quality, completeness and accuracy of medical record documentation through interaction with physicians and other business partners. Ensures clinical documentation reflects the level of service, severity of illness, risk of mortality is complete, accurate and successfully facilitates the accurate representation of a patient’s medical records that translates into coded data.


    • Able to collaborate extensively with physicians, nurses, other caregivers, and medical records coding staff to improve quality and completeness of documentation of care provided and coded
    • Assist in the collection and analysis of risk adjustment data in-order to identify documentation, coding trends and opportunities
    • Audit medical records for accuracy of coding, ambiguous, conflicting or incomplete documentation.
    • Conducts concurrent review of the medical records to increase the accuracy, clarity and specificity of provider documentation.
    • Provide feedback to providers and external/internal business partners of audit findings and make recommendations as necessary.
    • Keeps current with changes in coding guidelines, compliance, reimbursement, and other relevant regulatory updates
    • Develop and coordinate education and training that focuses on Risk Adjustment coding and documentation opportunities utilizing a variety of methods to deliver content, such as direct provider collaboration, power point presentations, teleconferences and webinars.
    • Partner with key business areas around provider education, engagement and develop follow up plans where appropriate.
    • Collaborate with internal business partners to achieve department objectives and ensure internal risk adjustment compliance and standards are maintained
    • Assumes responsibility for professional development by participating in workshops, conferences and/ or in-services.
    • May be called on to present to large and/ or small groups of executives, physicians and other clinical or financial personnel
    • Assist with coding chart review projects and RADV audits
    • May be required to Audit vendors and internal coders work




    Minimum of Bachelor’s degree, preferably a BSN in Nursing or related clinical experience.



    • Possession of AHIMA (American Health Information Management Association) or AAPC (American Academy of Professional Coders) of any of the following Certified Coding Specialist (CCS), Certified Risk Adjustment Coding (CRC) or Certified Professional Coder (CPC) required.
    • RN Licensure preferred


    • Strong organizational skills in multiple settings, as well as the ability to exercise judgement and initiative
    • Strong written, verbal and presentation skills 
    • Possess Critical Thinking skills
    • Competent in MS Office
    • Proven/demonstrated knowledge in the following
    • ICD-10-CM Coding/Risk Adjustment HCC coding
      1. Regulatory Compliance
      2. HIPAA and Legal Aspects of Health Information
      3. Medical Reimbursement Methodologies
      4. Medical Terminology
    • Self-motivation with excellent follow through skills with ability to work independently with minimal to moderate supervision with demonstrated ability to work as an effective team member
    • Adaptive and flexible to new ideas and change
    • Travel to provider offices
    • Experience working and interacting with the Provider community
    • Preferred: 2 year of Clinical Documentation Improvement (CDI) experience in the inpatient/outpatient setting 
    • Thorough knowledge of ICD-10-CM, Medicare, Medicaid, Commercial HCC coding guidelines
    • Previous experience with Risk Adjustment coding is preferred



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