Fallon Health

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Claims Quality Assurance Auditor

Claims Quality Assurance Auditor

Job ID 
# Positions 
Posted Date 
Claims Administration

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:

Conduct Quality Assurance Audits of claims adjudicated by the Claims Administration Department staff and auto adjudicated claims to ensure high quality using the quality manual as a guideline. Proactively updatethe quality process/manual as appropriate or specifically when change packs, new products/programs, and/or new processes are implemented. Identify error trends and training opportunities and proactively report those observations to the appropriate Claims Manager of the staff to ensure corrective action is taken.   Collaborate with the appropriate departments for resolution of issues identified during audits. Represent your error decision at the appeals committee with fact and sound justification.



  • Review claim for processing accuracy using expert knowledge of claim processing and the Quality manual as a guideline.
  • Identify and trend issues and report to manager and QA team to ensure team collaboration and process improvement as needed.
  • Update quality process/manual to support change packs, new programs/ products, and/or new processes.
  • Actively participate in team meetings and keep current on training and other communication affecting claim processing and quality results.
  • Collaborate with other departments to resolve issues identified during audits.
  • Communicate errors to staff and Department Managers and ensure identified errors are corrected.
  • Propose training based on audit results and trending.
  • Collaborate with other departments (Provider Reimbursement, Benefits Configuration, etc) on errors found while reviewing auto adjudicated and/or staff adjudicated claims. Request timely remediation plan and coordinate testing of changes as needed.
  • Report to management all corrective action plans with other departments.
  • Document errors in data base and provide back-up documentation.
  • Communicate with EDI staff of data entry vendor errors and ensure they are tracked through remediation.
  • Ensure timeliness and accuracy of information entered into data base for accurate month end reporting.
  • Ensure accuracy of information for MAR reporting.
  • Produce month end report for each claim staff audited

  • Distribute staff report to management with clearly defined errors.

  • Distribute finalized department audit to management

  • Review disputes to determine if error is valid based on additional information provided.

  • Actively participate and represent the QA team professionally and positively at the Appeals Committee and present rationale for errors.

  • Work with Department Trainer as needed to validate errors as needed

  • Excellent communication skills and empathy when working with staff is essential in this position. Provide rationale on all errors. Stick to the facts without adding personal commentary.
  • Ensure consistent communication or errors without management commentary. Performance related communication should always come from the manager not the auditor.
  • Provide education to staff on errors and where to find training materials as needed.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's Degree preferred



  • Minimum of 5 years experience working in a managed care environment. Claims Department preferred.
  • Must have high degree of self-motivation and excellent judgment
  • Fluency with Microsoft Office.
  • Excellent communication skills, both oral and written with all levels of staff.
  • In depth knowledge of claims processing, enrollment, COB, contracting.
  • Experience as a claims examiner is preferred
  • QNXT experience predferred
  • Demonstrated integrity, values, principles and work ethic.
  • Ability to analyze issues, recommend solutions, and escalate as needed
  • Excellent organizational skills