Fallon Health

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Director of Quality & Care Management-Growing Health Care

Director of Quality & Care Management-Growing Health Care

Job ID 
4949
# Positions 
1
Location 
US-MA-Worcester
Posted Date 
10/4/2017
Category 
Quality

More information about this job

Overview

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.

 

Position Overview:

Provides overall direction to the Quality Services Department with responsibility for HEDIS® submission to NCQA, Medicare and Medicaid clinical quality programs and accreditation. Directs all areas related to quality and compliance with NCQA, Division of Insurance, and Center for Medicare and Medicaid, and federal and state regulations. Provides oversight on behalf of the health plan to all vendors that are delegated with managed care functions to ensure that all downstream entities comply with NCQA and other regulatory requirements related to quality.  Interacts with other departmental directors to merge the quality services activities with marketing and sales, care services, credentialing and member relations as well as other senior leaders, directors and managers within the health plan.

 

Responsibilities

  • Provides leadership, trains, develops and evaluates direct reports. Hire for, on board, and develop a successful team.
  • Responsible for all quality activities within the health plan, including the infrastructure, committees, reporting, and outcomes measurements in order to comply with the national accreditation with NCQA (National Committee for Quality Assurance) and federal and state regulatory requirements.
  • Provides oversight to the government programs, Medicare and Medicaid quality programs and ensures that Fallon Health meets the requirements for the Center of Medicare and Medicaid and the Massachusetts Division of Medical Assistance contractual requirements
  • Develops and implements policies and procedures that ensure compliance with legal and other external regulations/requirements and supports the continuous improvement of the quality of service provided by the department.
  • Directs the plan’s HEDIS data collection and improvements, and  specific quality programs and other related activities to clinical quality.
  • Increases standardized quality scores used by NCQA particularly HEDIS by implementing specific health activities that promote the rates.
  • Leads the population based programs to improve the health and wellness of Fallon Health members by implementing interventions that will motivate members to participate in preventive screenings.
  • Collaborates with physicians within the network to remind them of members who have not received appropriate screenings and treatments according to nationally recognized guidelines.
  • Establishes a budget for Quality Services that provides adequate resources, materials, and personnel to serve the health plan’s quality infrastructure and continuous monitoring of the quality program as well as tracking expenses and documenting rationale for variances.

Qualifications

Education: Master’s Degree in health administration, public health, nursing or related health preferred

License: Nursing or other related discipline preferred

Experience: Minimum of 3-5 years experience in a leadership role within a health care setting directing quality management and care management programs with an emphasis on measurable outcomes based on application of continuous improvement principles. Must demonstrate a proven track record in achieving measurable healther services improvements and knowledgeable about accreditation requirements and HEDIS® and regulatory
requirements.

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