Fallon Health

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Medicare Regulatory Affairs Manager

Medicare Regulatory Affairs Manager

Job ID 
# Positions 
Posted Date 
Medicare Medicaid Programs

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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.


Brief Summary of Positions:

The Medicare Regulatory Affairs Manager acts as a regulatory resource to clarify, monitor and research regulatory requirements and changes that impact the structure and operation of Medicare Advantage, PACE and other Medicare products. The scope of the position includes regulations pertaining to Medicare Advantage, PACE and other Medicare products, such as Medicare applications, including RFI and RFA applications, and expansion applications and compliance oversight. Additionally, this position includes responsibilities for policies and procedures as a Fallon Policy and Procedure Librarian, such as sending annual review policy and procedure reminders and providing education on the development of policies and procedures


  • Conduct research regarding regulatory and benefit questions to support business requirements including product development, procedural issues and changes for Medicare Advantage, PACE and other Medicare products.
  • Conduct research and analyses of matters related to existing and new regulatory requirements.
  • Assume a major role in CMS and State monitoring preparedness by leading work groups and developing work plans that focus on readiness and compliance with CMS and State regulations, manuals and review guides including, but not limited to, the fraud, waste and abuse oversight requirements.  
  • Provide support to Medicare Advantage, PACE and other Medicare products application submission process and other submissions as needed.
  • Develop and and prepare arguments and explanations in response to proposed regulatory changes and inquiries.
  • Seek advice from legal counsel.
  • Assist with the compliance oversight of Fallon’s First Tier, Downstream and Related Parties (FDRs).
  • Manage the review and revision process of Medicare Programs policies and procedures.
  • Develop, update and/or revise relevant policies and procedures within Medicare Programs based on updates to interpretation or regulatory changes from state or federal regulators.
  • Act as a Policy and Procedure Librarian for certain business areas throughout the organization. This includes sending reminders of the annual reviews as well as providing education on what policies and procedures are and what they are to contain.
  • Assist operational areas, as needed, with the development, updates and/or revisions relevant policies and procedures based on updates to interpretation or regulatory changes from state or federal regulators.
  • Manage the development and monitoring of compliance in line with the State and Federal requirements, including:
  • Reviewing and retaining company contracts and other documents pertinent to the Medicare/Medicaid product(s)
  • Managing the submission of data to CMS and/or the State to ensure it is accurate and in compliance with reporting requirements and timeline.
  • Coordinate with business areas to gather information needed for regulatory reviews, validations and audits.
  • Provide support during audits, to Medicare Advantage and PACE product(s) application submission process and other submissions, and other Medicare Programs special projects and assignments as needed.    


Education:  Bachelor’s degree required. Advanced degree in law strongly preferred for this position      


Experience:  5 years managed care or relevant industry experience