Overview:
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:
The Clinical Documentation Review RN is responsible for auditing care plans, health risk assessments, MDS assessments and other clinical documentation to ensure accuracy, completeness, and compliance. This role supports quality of care and regulatory adherence by reviewing documentation against CMS and state contractual guidelines. The reviewer provides feedback and guidance to clinical teams to promote accurate, consistent and compliant documentation that reflects the member’s health status and care needs.
Responsibilities:
Primary Job Responsibilities:
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Audits documentation ensuring documentation meets quality standards and interventions and actions are effective to meet member needs
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Conduct audits of medical records to verify that documentation supports the services provided, meets regulatory standards, and aligns with SCO program requirements.
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Ensure interdisciplinary care plans are updated and reflect current member needs and are in compliance with regulatory and accreditation requirements.
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Confirm that assessments are documented and integrated into care planning.
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Audit MDS-HC forms entered into the State’s System to ensure compliance with current Supplemental Instructions
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Audit documentation for evidence of care coordination across medical, behavioral health, and long-term services.
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Ensure transitions of care (e.g., hospital discharge) are documented with follow-up plans and communication between providers.
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Identify documentation gaps that may impact care coordination, reimbursement, or compliance with MassHealth, CMS, and SCO-specific guidelines.
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Collaborate with providers and care teams to clarify clinical documentation through queries and feedback, ensuring accurate reflection of patient acuity, diagnoses, and care plans.
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Monitor trends and patterns in documentation errors or omissions and recommend corrective actions or process improvements.
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Educate clinical staff on best practices for documentation, including SCO-specific standards, regulatory updates, and audit findings.
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Participate in interdisciplinary and team meetings to provide insight into documentation quality and contribute to care planning and compliance strategies.
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Maintain audit logs and reports to track findings, follow-up actions, and performance metrics related to documentation quality and integrity.
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Collaborate with departments throughout Fallon to ensure documentation aligns with company policies and procedures.
Qualifications:
Education:
Graduate from an accredited school of nursing mandatory and a Bachelors (or advanced) degree in nursing or a health care related field preferred
License/Certifications:
License: Active, unrestricted license as a Registered Nurse in Massachusetts
Certification: Certification in Case Management preferred
Other: Satisfactory Criminal Offender Record Information (CORI) results, reliable transportation
Experience:
4+ years job experience as a Registered Nurse working in a care management/care coordination role in a managed care payor operating a dual Special Needs Plan required.
Experience with NCQA, CMS, and other required regulatory requirements and experience writing and developing policies and process documents required.
Experience with developing audit tools, auditing team member performance, and working with staff to improve their performance preferred.
Demonstrated proficiency including but not limited to:
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Ability to develop a system and process to objectively measure care management competencies and to hold team members accountable, including, but not limited to developing corrective action plans, as appropriate
- Ability to identify gaps in staff’s knowledge base and to design training materials to address those gaps
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Ability to teach others in an organized and structured manner utilizing adult learning principles and collaboration skills
- Advanced skills in software systems including but not limited to Microsoft Office Products – Excel, Outlook, and Word
- Manipulation of Excel spreadsheets to manage work and exposure and familiarity with pivot tables desirable
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Working with an interdisciplinary care team as a partner demonstrating respect and value for all roles and is a positive contributor within job role scope and duties
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Knowledgeable about medical record documentation
- Critical thinking skills for independent problem solving
- Prior experience with clinical documentation review, quality audits, or utilization review preferred.
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Familiarity with chronic disease management, care planning and transitions of care.
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Experience with Minimum Data Set- Home Care assessments and requirements associated with such.
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Access and ability to navigate the State’s Virtual Gateway platform for MDS-HC review and submission
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Excellent attention to detail, analytical skills, and ability to identify discrepancies in documentation.
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Proficiency with EMR systems and audit tools.
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Strong written and verbal communication skills; ability to provide constructive feedback to clinical staff.
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Strong knowledge and understanding of current State Supplemental Instructions for MDS-HC submission for rating category assignment
Pay Range Disclosure:
In accordance with the Massachusetts Wage Transparency Act, the pay range for this position is $110,000 - $115,000 per year, which reflects what we reasonably and in good faith expect to pay at the time of posting. Final compensation will depend on the candidate’s experience, skills, and fit with the role’s responsibilities.
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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.
