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 fallonhealth.org.
Brief Summary of purpose:
The Clinical Investigator- Nurse Coder will conduct comprehensive code reviews of medical claims, medical records and other documents supporting claims for medical and behavioral health care services to identify potential over-payments and suspected fraud waste and abuse. Plan, organize, and execute medical reviews or audits that identify, evaluate and measure potential healthcare fraud waste and abuse. Serves as a clinical liaison for fraud, waste and abuse team while identifying areas of vulnerability and risk.
The Internal Audit Department (IA) at Fallon Health (FH) is the designated Fraud, Waste and Abuse Unit for the company. As such, it's IA's responsibility to provide guidance and oversight regarding preventive and detective activities. IA reports administratively to the Chief Compliance Officer and functionally to the Audit & Compliance Committee, and plays a key role in employing various procedures to detect fraud, waste and abuse.
Primary job responsibilities:
- Perform clinical coding review to ensure accuracy of medical coding and utilizes clinical expertise and judgment to determine correct coding and billing.
- Reviews medical records, attending physician statements, and care management reports which requires interpretation of state and federal mandates, applicable benefit language, medical and reimbursement policies in the evaluation of cases involving potential allegation of FWA
- Identify aberrant billing patterns and trends, evidence of fraud, waste or abuse, and recommend providers to be flagged for review.
- Perform root cause analysis for issues and recommend changes to the Director.
- Maintain and manage daily case review assignments, with a high emphasis on quality.
- Work closely with clinical teams as well as Medical Directors; including external partners and providers.
- Help to mitigate FWA globally by providing feedback to management related to trends and schemes.
- Prepares concise clinical review summaries / investigative summaries to support findings of potential fraud, waste and abuse, which includes case updates on progress of medical reviews to internal departments, committees and management.
- Maintains reports of pending investigations and fraud related litigation and schedules and presents regular updates to Director of the department and upper management and to business partners, regarding pending fraud investigations and fraud litigation.
- May assist in responding to various regulatory agencies complaints and may file, or assist in the filing of, fraud reports as required by state and federal agencies.
- Reports potential issues identified that relate to the Fallon's Fraud, Waste and Abuse policy. Including, but not limited to, billing for services that were not provided, intentional misrepresentation or the deliberate performance of unwarranted or medically unnecessary services for the purpose of financial gain.
- Make recommendations for member/provider/employee education related to the findings.
- Analyzes evidence to provide management with an evaluation of the adequacy of financial and operational controls and make recommendations for improvement.
- Must be willing to testify in civil and criminal matters.
- Ability to communicate effectively both verbally and in writing strong listening skills, can work independent and ability to meet definedperformance and production goals.
Graduate of accredited school of Nursing
RN Licensure required
Certificate of Professional Coding (CPC) required. CPMA expertise and/or Certified Fraud Examiner (CFE) a plus
Required yearly CEU education to maintain coding certification and membership to AAPC.
Five years clinical experience or RN experience.
Three+ years' experience conducting medical review and coding/billing audits preferred.
Knowledge and understanding of medical terminology along with comprehension of knowledge of coding including CPT, HCPCS, ICD-9/ICD-10, Revenue Codes, and DRG.