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.
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
Bachelor's Degree preferred