Fallon Health

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Summit Elder Care Senior Director, Operations

Summit Elder Care Senior Director, Operations

Job ID 
5052
# Positions 
1
Location 
US-MA-Worcester
Posted Date 
1/9/2018
Category 
Senior Leadership

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.

 

About Summit ElderCare:

 

Fallon Health operates the largest Program of All-Inclusive Care for the Elderly (PACE) in New England and the fifth largest in the country. Called Summit ElderCare, Fallon’s PACE helps provide older adults and their caregivers with a welcome alternative to nursing home care. Participants in Summit ElderCare have access to comprehensive medical services and social support at a Summit ElderCare site while they keep the independence of living in their own homes and communities.

Brief Summary Purpose:

Provides program-wide clinical and administrative operations leadership, direction and oversight to ensure high quality care that maximizes efficiency, regulatory compliance, member and staff satisfaction, positive internal and external business partner relationships and achievement of Summit ElderCare and Fallon Health strategic goals and initiatives. Works closely with SE VP/Executive Director and SE VP/Medical Director to carry out the SE mission of keeping members living safely in the community; collaborates with other FH Senior Care Products to optimize administrative efficiencies

Responsibilities

With general direction from the Summit ElderCare VP/Executive Director, the Senior Director is responsible to ensure that all SE site operations are in compliance with Fallon Health Corporate and Summit ElderCare policies and procedures as well as CMS/PACE regulations.

                             

Participates as a member of SE Leadership Team to assist in establishing program goals and strategies in accordance with corporate objectives, regulatory, marketplace and financial conditions:

 

  • Participates in development of and participation in Summit ElderCare’s strategic and business initiatives
  • Adjusts Summit ElderCare business plans as needed to support FH and SE strategic and business goals

 

Works closely with PACE Program Manager to coordinate SE compliance with all Medicare and Medicaid insurance related regulatory requirements in accordance with FH administrative requirements, including:

  • CMS Program Audit (preparation and implementation of any corrective actions)
  • Medicare enrollment
  • Premium/cost share billing
  • Medical payment policy
  • Service authorizations
  • Claim payments
  • Medicare Part D support
  • Ensure appropriate SE representation on relevant committees and workgroups

Provide overall management and administration of the electronic medical record/program management (EMR/EPM) system and other selected applications for the management of dually capitated models of care:

  • Provide operational leadership and development of practices and systems that leverage the electronic participant record and other systemic practices to automate processes and achieve quality goals
  • Work collaboratively with the PACE Application Support team to ensure ongoing EMR system and database integrity
  • Collaborate with SE Leadership, PACE Application Administrator, FH IT staff and external vendors and providers to lead identified EMR system interface efforts with other provider and FH systems.

 

Ensure timely completion of contracted vendor audits and associated corrective action plans in accordance with SE policies and procedures and regulatory requirements:

  • Oversee vendor audit process to ensure timely audit, submission of corrective action plans and timely resolution of all identified deficiencies
  • Ensure all outstanding audit findings are escalated to the Contracts Manager(s) and Provider Relations representative(s) in a timely manner 

Provide day to day leadership and oversight to ensure achievement of business goals and consistent program operations across multiple sites:

  • Utilizes lean principles to implement business processes across sites to maximize efficiencies and reduce costs
  • Assist in training and coaching Site Directors, and other operations support staff to ensure staff proficiency in the PACE clinical, social support and insurance functions.
  • Collaborate with SE leadership and site staff to develop and implement plans for achieving financial, enrollment and other programmatic goals.
  • Collaborate with SE leadership and relevant FH staff to resolve problems and to pursue identified improvement opportunities. Define, document and communicate revised workflows and ensure that policies and procedures are updated to reflect current practice and accountabilities.
  • Collaborate with PACE industry peers to benchmark performance in identified areas and to promote sharing of best practices.
  • Conduct regular staff meetings with cross functional and discipline specific groups to promote sharing of information, cross communication across sites, collaborative problem solving and staff satisfaction.
  • Serve as primary point of contact for selected program vendors to assure consistent operations, vendor satisfaction, vendor accountability and a strong financial negotiating position

Assist with the annual budget process and ongoing financial improvement activities:

  • Assist the SE VP/Executive Director and Site Directors in preparation of the annual program/site budgets and continuously monitors expenses
  • Prepare the annual program budget for operational departments
  • Assist with quarterly reforecast process for program, sites and operational department

Provide operational guidance and support for the SE Quality & Risk Department and related activities:

  • Work in collaboration with the SE VP/Medical Director, SE VP/Executive Director, SE Director of Quality and Risk as well as other staff to ensure that an annual quality work plan is developed in accordance with identified quality improvement opportunities and regulatory requirements.
  • Work in collaboration with the SE VP/Medical Director and SE Director of Quality and Risk to ensure site staff is competent with regard to investigation of incidents and grievances process

Facilitate ongoing adherence to Fallon Health billing and financial policies and procedures via ongoing coordination of: 

  • FH Premium billing with GPES staff
  • SE Medicaid Coordination with GPES staff
  • Processing invoices for payment by office staff across the SE sites

 

Lead the maintenance of accurate and updated Enrollment Agreements, provider manuals and ID cards in collaboration with SE Leadership and FH staff to ensure regulatory approvals are in place and, when applicable, resolve identified issues:

  • Ensure communications department staff is aware of and approves all new or revised PACE materials
  • Ensures SE sites utilize only those documents and materials that have been approved and are posted on the SharePoint site.

In collaboration with PACE Program Manager, monitor and analyze relevant insurance and administrative regulatory requirements via:

  • National PACE Association (NPA)
  • Centers for Medicare and Medicaid Services (CMS)
  • State list serves
  • FH Committees

Oversee implementation and maintenance of SE Policy and Procedures via the SharePoint site. Support corporate policy ensuring SE policies and procedures are reviewed annually.

Recruit, train and manage direct reports to ensure staff competency and to promote staff, customer and vendor satisfaction.

Represents SE on external or FH committees/workgroups and with state and federal regulators as requested by the SE VP/Executive Director. Serve as a resource to MassPACE Association.

Qualifications

Education:

Bachelor of Science in Nursing or other professional degree in a clinical area of study required; Masters’ Degree in Nursing, Health Care Administration, Public Administration, Business Administration or related field preferred.

 

Experience:

Minimum of six years of nursing and/or other clinical experience in a health care setting preferably with frail seniors; Minimum of five years management and supervisory experience in a health care setting; previous managed care or insurance industry experience strongly desired; minimum of five years of experience in health care, elder services, business administration or related field. Knowledge of regulatory requirements for health insurance industry, excellent written and oral communication skills, excellent organizational and analytical skills, strong problem-solving skills and conflict resolution skills; strong ability to lead teams and manage projects from start to finish. 

 

Competencies:

  • Coaching and developing others
  • Decision Making
  • Problem solving
  • Fosters open communication
  • Exercises Independent judgment
  • Adaptability
  • Approachability
  • Facilitates Change
  • Customer Focus
  • Leadership Presence
  • Strategic Perspective
  • Uses Systems to Achieve Results

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