Fallon Health

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Manager, UM Clinical Services - FALLON HEALTH - Growing Healthcare Company!

Manager, UM Clinical Services - FALLON HEALTH - Growing Healthcare Company!

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Utilization Management

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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:

  • Accurate and timely information on all Members admitted to an inpatient facility is captured and disseminated to the appropriate staff on a daily basis.
  • The staff utilizes approved FH criteria in addition to InterQual and Medicare guidelines when completing admission, concurrent and retrospective reviews.
  • Appropriate and timely discharge planning activities take place on a daily basis.
  • 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.

  • Departmental utilization and budgetary goals are met on a monthly, quarterly and annual basis.


Primary Job Responsibilities:

  • Hires, orients, supervises, evaluates, counsels and terminates staff that function within the Inpatient Care Management/Discharge Planning Unit. 
  • Establishes productivity and professional goals with staff and evaluates performance based on these defined goals. 
  • Conducts staff meetings on a regular basis. 
  • Meets 1:1 with UM nurses on a regular basis. 
  • Develops, creates, and disseminates reports to effectively manage and continuously improve the Inpatient Care Management/Discharge Planning Program. 
  • Creates reports to monitor inpatient utilization (UM Nurse) productivity and performance. 
  • Performs quality and inter-rater reliability audits on a regular basis and in compliance with departmental policies and procedures. 
  • Collaborates with the Sr. Director of IUM, Medical Directors and data analysts to design reports that support the informational requirements of the UM initiatives. 
  • Ensures that Care Management Standards of Practice are utilized in the daily operational processes of inpatient reviews and discharge planning through ongoing internal audits. 
  • Creates, disseminates, implements, and monitors UM Policies and Procedures as necessary. 
  • Works with the Care Management Operations Directors, Managers and Medical Directors to develop and implement approved inpatient and discharge planning strategies. 
  • Acts as a resource and educator for the UM Team and prior auth staff in resolving administrative and clinical issues that arise during the inpatient concurrent review/discharge planning process. 
  • Coordinates the UM nurse role interdepartmentally, intra-departmentally and with external customers. 
  • Develops and conducts education / training sessions regarding healthcare services available in the FH system and the community for FH physicians, nurses and ancillary staff.
  • 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. 

  • Strictly observes the HIPPA regulations and the FH policy regarding confidentiality of member information. 
  • Interfaces with appropriate personnel at contracted and non-contracted facilities to improve the working relationship and to resolve member and utilization issues. 
  • Identifies departmental Policies and Procedures that require re-assessment and discusses them with the Sr. Director. 
  • Co-travels with staff when applicable, specifically with the Embedded Care Management program staff. 
  • Implements Quality Improvement activities as designated by management. 
  • Performs other responsibilities as assigned by the Sr. Director.


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.


  • A minimum of three to five years clinical experience as a Registered Nurse, Social Worker or Healthcare Administrator in a clinical setting required.
  • 2 years’ experience as a Utilization Management nurse in a managed care payer preferred.
  • One year experience as a case manager in a payer or facility setting highly preferred.
  • Discharge planning experience highly preferred.
  • Experience in a healthcare field if non-nurse.
  • Experience in a payer setting.