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
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:
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:
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:
Ensure timely completion of contracted vendor audits and associated corrective action plans in accordance with SE policies and procedures and regulatory requirements:
Provide day to day leadership and oversight to ensure achievement of business goals and consistent program operations across multiple sites:
Assist with the annual budget process and ongoing financial improvement activities:
Provide operational guidance and support for the SE Quality & Risk Department and related activities:
Facilitate ongoing adherence to Fallon Health billing and financial policies and procedures via ongoing coordination of:
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:
In collaboration with PACE Program Manager, monitor and analyze relevant insurance and administrative regulatory requirements via:
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.
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.
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.