Fallon Health

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Senior Leadership

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The Opportunity!
Massachusetts Medicaid officials announced recently that 17 health care organizations statewide have signed up to participate in a major restructuring of the MassHealth program, shifting more members into networks of physicians, hospitals and other community-based providers working together as Accountable Care Organizations, or ACOs. Fallon Health was awarded 3 of these new ACO partnerships and will be an integral part of this new endeavor and with our experience providing integrated care through other government programs, we are perfectly positioned to provide outstanding care and excited about our new partnerships and growth potential.

To support this highly visible business initiative Fallon Health is looking for a new Medical Director. This is fantastic opportunity for an innovative physician leader interested in making a significant impact in the MassHealth Medicaid/ACO arena. The right individual will have a passion and track record of successful sustainable partnerships that brings together physicians, hospitals, insurers and other health care providers that work in harmony to provide integrated care with the goals of improving health outcomes and containing costs.

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


This is a newly created role reporting directly to Fallon’s Chief Medical Officer. Our new Medical Director for Medicaid will oversee the clinical care management of the ACO Medicaid populations; identify trends and opportunities and develop and implement solutions and initiatives to manage patient outcomes and TME successfully; and ensure quality of care to all Medicaid members and successful outcomes in all quality measures required by MassHealth and Massachusetts EOHHS.

You will establish close working relationships with the clinical leadership of our (3) new ACO partners. In addition you will ensure compliance with all regulatory and accreditation agencies and laws including but not limited to CMS, EOHHS, NCQA, and HIPAA pertaining to all clinical activities and interventions.

The Medical Director for Medicaid works collaboratively with the Executive Director of Medicaid to support activities necessary to provide service to our ACO partners and to EOHHS.

  • Works with the our ACO partner Medical Directors to ensure the effective oversight and leadership of the overall Program and member experience.
  • Provides oversight and direction to ensure collaboration between Fallon’s Care Services department including pharmacy and behavioral health and the ACOs.
  • Works collaboratively with Fallon’s Network Development department, including provider relations to help contract providers and explain Fallon policies.
  • Works with Fallon’s Medical Economics Department to develop and deliver actionable utilization and cost data to ACO providers.
  • Implements clinical program specific action plans, strategies and timelines.
  • Manages all resources so as to meet clinical program performance goals, targets and standards. These include but are not limited to Total Medical Expense (TME); Medicare Stars Performance; member outcomes; member and provider satisfaction.
  • Develops and maintains strong clinical relationships with key vendors providing critical services to Medicaid members including the ACO providers and Beacon Health Strategies.
  • Develops and maintains a collaborative working relationship w/ the Medicaid Executive Director, and the Medicaid department at Fallon Health.
  • Establishes and maintains effective and collaborative relationships with other key internal and external customers and constituencies including but not limited to providers, regulators, advocacy groups and the home and community based care providers and agencies.
  • Leads staff in the achievement of high quality performance and team orientation.
  • Works with ACO medical leadership to ensure overall Program processes, policies, and workflows are documented and updated on an ongoing basis to meet current Program needs.
  • Oversees the development and maintenance of all departmental policies, procedures and guidelines and ensures their compliance with all regulatory and accreditation agencies.
  • Oversees the Program compliance for all clinical activities with all appropriate regulatory and accreditation agencies including but not limited to CMS, EOHHS, and NCQA.
  • Ensures team’s compliance with all legal requirements and policies regarding member confidentiality including but not limited to HIPAA regulations and FCHP policies.
  • Provides the clinical representation for FH and Medicaid to support the reputation and growth of FH in existing and emerging markets. This includes presentations and attendance at conferences, meetings, and hearings as needed under the supervision of the EVP and CMO of Care Services and at the request of the Executive Director of Medicaid.
  • Works closely with Care Services Leadership staff to work with provider groups in medical management of their members. This includes but is not limited to utilization management, cost of care and population health management.
  • Participates in the on call rotation for FH Care Services after hours call, responding to approval, appeals and grievance and other activity after hours.
  • Performs other tasks and responsibilities as determined by the EVP and CMO of Care Services to ensure successful outcomes in all Medicaid programs, quality of care provided to Medicaid members, and clinical activities necessary to support FH’s ACO partnerships


  • Minimum of five years’ experience in managed care, or managing health care delivery
  • Minimum of five years in clinical practice
  • Previous direct experience in managing or leading Mediciad programs highly preferable
  • Previous management experience highly preferred
  • Previous program development and policy development experience highly preferred
  • Previous teaching experience to an audience of nurses and paraprofessionals regarding complex medical conditions commonly experienced in a managed Medicaid population
  • Previous experience presenting in front of audiences utilizing power point or other prepared presentations
  • Experience with MassHealth and MassHealth Medicaid reform a strong plus
  • Knowledge of DSRIP(delivery system reform incentive payment) a strong plus
  • Experience and expertise in providing care management to vulnerable populations
  • Experience and knowledge of racial and ethnic disparities in health care
  • Experience with Federally qualified health centers a plus