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.
The Manager of UM manages all staffing and activities related to inpatient admissions for all levels of care (acute, acute rehab, skilled nursing facility – SNF) which includes but is not limited to admission, concurrent and retrospective reviews and discharge planning. Along with other members of the medical management leadership team, the Manager is responsible for the quality and cost effectiveness of care provided to Fallon Health (FH) members. Specific responsibilities include:
Required utilization reports are created and disseminated on a daily, monthly, quarterly and annual basis.
Appropriate staffing levels are maintained for the UM Team.
Ongoing development and implementation of new strategies, processes, policies and procedures related to the UM program are in compliance with governmental, accrediting agency and health plan requirements.
Primary Job Responsibilities:
Interfaces and resolves issues with contracted and non-contracted vendors for all ancillary care (e.g., home health, DME, Infusion Therapy, Outpatient Rehab Facilities, etc.) to ensure appropriate quality of care and service is delivered to FH members.
Participates in research activities to establish benchmarks for care management in the development and implementation of best practices.
Education, Licenses, certification and experience requirements:
Education: Graduate from an accredited school of nursing, or Bachelors (or advanced) degree in nursing, or Rehabilitative Services (i.e. Physical or Occupational Therapy), Social Services or healthcare administration required.
License: If a nurse, must have an active, unrestricted license as a Registered Nurse in Massachusetts.