Fallon Health

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Medical Claims Reviewer- CPC-Certification Required! Growth at Fallon Health!

Medical Claims Reviewer- CPC-Certification Required! Growth at Fallon Health!

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 Medical Claims Reviewer is responsible for all aspects of medical claims review including: determining the appropriateness of service, setting, service billing code, eligible benefits, contractual agreement, authorization and claims payment mediation, negotiation and adjudication. Processes complex claims and ensures correct payment of authorized claims following established protocols. Ensures 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. This position will advise and make recommendations to Medical Review and Corporate Leadership.


Primary Job Responsibilities (Include duties that represent 5% or more of employee’s time)

  • Meet all department standards: productivity; quality; and attendance.
  • Comply with all department, company, and industry guidelines including all applicable laws and regulations.
  • Familiar with all Medicare regulations related to fee-for-service and managed care eligible benefits and claims payment
  • A working understanding of all aspects of contractual managed care to include risk arrangements, capitation, fee-for-service, etc.
  • Knowledgeable of current and possible future policies, practices, trends and information affecting his/her business and organization
  • Working knowledge of Medical Quality Management processes
  • Knowledgeable in all areas of Referral Management including Prior Authorization
  • Reviews claims to determine the appropriateness of the service, setting, billing code, eligible benefits, contractual agreement, authorization. and correct adjudication
  • Makes independent clinical decisions utilizing criteria and guidelines, minimizing need for Medical Director review of claims
  • Identifies provider billing trends/issues which require further investigation or ongoing intervention, education and interacts with Medical Directors and Provider Relations as needed
  • Analyzes claims data and claims audits to enhance savings and take appropriate corrective actions internally with Claims, Provider Relations and Contracting staff
  • Works with internal and external partners to educate/implement corrective actions
  • Interacts with Medical Directors as needed
  • Effective in a variety of formal presentation settings: one-to-one, small and large groups, with peers and leadership
  • Participates on Corporate-Level Committees, Project Teams and Workgroups
  • Participates in developing policies and procedures
  • Knowledgeable in accessing research databases, such as the Agency for Healthcare Research and Quality (AHRQ), Encoder, internet search engines and Medline
  • Appreciation for the financial implications of medical resource utilization
  • 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.



Bachelors' Degree in Business and/or Nursing preferred



Required to possess CPC (Certified Professional Coder), “H” (Hospital) Certification, CCS (Certified Coding Specialist) or CCS-P (Certified Coding Specialist Physician-Based)



Clinical practice experience in an acute care setting preferred.

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 or equivalent experience

Solid working knowledge of CPT, ICD-10, HCPCS coding guidelines, and medical terminology

Understanding of medical billing (CMS1500/UB04)

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