Fallon Health

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Claims Payment Integrity Auditor

Claims Payment Integrity 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:

The Claims Payment Integrity Auditor ensures payment resolution for identified claim overpayment recoveries in a timely, accurate, and efficient manner. Process complex claims and ensure correct payment of authorized claims following established protocols. Ensure compliance with contract administration, and service level requirements through claim reviews and client appeals. This position will work with other departments, project teams and committees as needed to resolve issues and contribute to policy and procedural improvements.


Negative/Credit Balance and Refund Checks duties (as assigned):

Manage the negative/credit balance process for Fallon Health, FHLAC, and FHW to ensure funds are recouped timely and accurately. Manage the refund check process for the Claims Department


Facility Audits duties (as assigned):

Manage the Hospital Bill Audit, DRG validation, implantable and high cost pharmaceutical audits.


Claim Savings duties (as assigned):

Responsible for claims impacted by code editing software. Assist the Medical Code Review staff, focusing on medical claims review for accuracy and compliance with existing policies and contracts.  




  • Meet all department standards: productivity; quality; and attendance.
  • Comply with all department and company guidelines including all applicable laws and regulations.
  • Work with internal and external partners to educate/implement corrective actions and recover overpayment's.
  • The following is intended to describe the general content of the requirements for the performance of the job. It is not to be construed as an exhaustive statement of duties, responsibilities or requirements.
  • 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.

 Claim Savings duties (as assigned):


  • Responsible for claim processing related to claim editing software
  • Testing and documentation of claim editing software functionality
  • Root cause analysis of claim editing issues
  • Monitor and identify billing areas for review and research.
  • Manage receipt of operative notes and facilitate claim processing related to Medical Code Review processes.

Facility Audits duties (as assigned):


  • Provide monthly claims file to vendors
  • Manage the facility audit process
  • Monitor and track audit activity

  • Handle provider appeal process

Negative/Credit Balance and Refund Checks duties (as assigned):


  • Analyze weekly negative balance reports.
  • Notify providers of negative balance status.
  • Work with Collection Agency and Credit Balance vendors
  • Monitor, track and process refund checks
  • Recommend Negative Balance Write-offs.




College degree preferred or equivalent work experience.



Certified professional/outpatient coder preferred



  • Minimum of 2 years health care industry experience; 2 years processing claims and/or adjustments or equivalent experience.
  • Claims auditing/processing experience and decision making based on analysis and problem solving.
  • Ability to communicate complex issues
  • Ability to collaborate with internal and external customers
  • Knowledge of Fallon Health policies and procedures
  • Solid working knowledge of CPT, ICD-10, HCPCS coding guidelines and medical terminology preferred
  • Strong analytical ability and communication skills
  • MS Office and general PC skills
  • Excellent organizational skills
  • Must possess the ability to prioritize tasks and follow through to completion
  • QNXT experience desirable