About us:

Fallon Health is a company that cares. We prioritize our members—always—making sure they get the care they need and deserve. Founded in 1977 in Worcester, Massachusetts, Fallon Health delivers equitable, high-quality, coordinated care and is continually rated among the nation’s top health plans for member experience, service, and clinical quality. We believe our individual differences, life experiences, knowledge, self-expression, and unique capabilities allow us to better serve our members. We embrace and encourage differences in age, race, ethnicity, gender identity and expression, physical and mental ability, sexual orientation, socio-economic status, and other characteristics that make people unique. Today, guided by our mission of improving health and inspiring hope, we strive to be the leading provider of government-sponsored health insurance programs—including Medicare, Medicaid, and PACE (Program of All-Inclusive Care for the Elderly)— in the region. Learn more at fallonhealth.org or follow us on Facebook, Twitter and LinkedIn.

Brief summary of purpose:

Under the general direction of the Senior Internal Audit Manager, the Analyze and interpret patient medical records pertaining to FWA investigations Compare to information submitted on the claims in order to determine amount and nature of billable services Determines appropriateness of billing and reimbursement Documents findings for each claim line Summarize findings in a written report Abstracts CPT, HCPCS, ICD-9/ICD-10, Revenue Codes, and DRG from medical records. Responsible for maintaining current knowledge of coding guidelines and relevant federal and/or state regulations Interface with other clinicians including internal Medical Directors Provide training to SIU staff related to clinical topics as neededFWA Manager will oversees the day-to-day operations over investigations and allegations into healthcare fraudulent, wasteful, and/or abusive billing and practices to mitigate related risks. This role will also assist in developing and maintaining FWA audit program, guidelines and procedures, and this individual must possess the expertise and experience to consult on the organization’s FWA practices. Additionally, this role will help to lead the implementation and ongoing execution of cost containment strategies.

To succeed in this role, the (FWA) Manager must be collaborative, decisive, an attentive listener, excel in developing and fostering relationships, work with integrity, and be a dedicated problem-solver.

Primary Job Responsibilities: 

• This position supports the Senior Director of Internal Audit in their leadership of the Fraud, Waste and Abuse (FWA) program. The FWA Manager will be responsible for general supervision over a number of staff engaged in FWA auditing activities, which may include the hiring, training, coaching, supporting in all facets of the jobs, and evaluating the performance of staff and the development of staff.
• Assist in the development, implementation and manage strategic fraud, waste and abuse (FWA) activities by maintaining state and federal requirements and monitoring trends/schemes.
• Develop customized fraud plans to meet contract and federal requirements.
• Oversee the reporting of Fallon’s external partners who support our Program Integrity efforts.
• Oversee any external FWA vendor(s) and make enhancement to the tool, reporting and monitor the staffing hours.
• Develop internal processes for enhanced FWA detection and investigation completion.
• Evaluate the FWA department policies and procedures to ensure compliance with federal and State regulations and make enhancement on daily processes.
• Oversee and conduct ongoing FWA activity to detect fraud, waste, abuse, including the tracking of audit activities and overall results by line of business for multiple external requirements. Serve as a lead for the team with responsibility for the day-to-day activity to investigate all possible fraud, waste and abuse referrals including the development of internal processes for enhanced FWA detection and investigation completion.
• Monitor and oversee data mining efforts of business processes and systems to assure integrity and compliance in billing and claims payment.
• Develop educational materials for new hire and annual compliance training programs, and conduct ad-hoc FWA training to internal customer on an ad-hoc basis.
• Participate in projects that may involve new vendors that process claims, or the expansion of new products and programs to ensure that FWA is included and policies per contractual obligation are updated.
• Attend state, federal and internal committee meetings as required.
• Provide in-depth progress reports to the Sr. Audit Director for review and prepare preliminary briefings on FWA findings resulting from investigations or other audit activity. These reports may be monthly, quarterly, semi-annually, or as required by State or for internal management. This may include trending, analysis, costs savings, and metrics.
• Prepare and distribute monthly and quarterly updates to various business partners.
• Work closely with other clinical and coder teams as well as Medical Directors, as needed.
• Make recommendations for member/provider/employee education.
• Ability to communicate effectively both verbally and in writing strong listening skills, can work independently and ability to meet deadlines.

Education: 

• Bachelor’s degree in business administration, healthcare, or related field; or equivalent relevant experience.
• Experience with Medicare and Medicaid and/or health insurance, a plus.

License/Certifications: 

• Certified Professional Coder (CPC) designation or similar.
• Additional certification applicable to this work is a plus, such as Certified Fraud Examiner (CFE), Accredited Healthcare Fraud Investigator (AHFI), or other coding certifications or similar in the healthcare industry.

Experience: 

• Advanced knowledge of FWA operations, fraud investigation and/or detection and analysis, and laws/regulations related to fraud and general risk management. Medical claim terminology, coding, and managed care expertise or clinical background.
• Strong attention to detail with the ability to identify fraud, assess the impact, resolve investigations, mitigate risk, and capture results.
• 5-8 years of related health care claims auditing experience in a complex healthcare environment, with at least 1 – 2 years of managing direct reports
• Experience working in health insurance specifically with claims processing, billing, reimbursement, coding, or provider contracting, a plus
• Ability to work with leaders to develop and document desired business capabilities and be able to translate those into system needs and requirements
• Demonstrated ability to effectively develop team members and monitor performance
• Exceptional organizational, communication, and interpersonal skills and ability to communicate effectively using written and verbal communication.
• Detail oriented with strong analytical and critical thinking skills
• Excellent computer skills and ability to effectively manage spreadsheets, develop presentations, organize files, and write letters and reports, plus, ability to effectively organize and prioritize in a multi-task, balance competing demands and work on assigned projects from inception to completion.
• Demonstrates a strong commitment to compliance and ethics
• Proficient with all Microsoft Office products, with at least an intermediate level of proficiency in Excel

COVID-19 Vaccination:

With the end of the Global Coronavirus COVID-19 Pandemic, Fallon Health no longer requires all employees to be vaccinated against COVID-19 except for employees who are in jobs that under state and federal laws, regulations and policies are required to be vaccinated and/or they are in Member/participant facing positions.

Fallon Health provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.