Fallon Health

  • Medicare Sales Compliance & Agent Oversight Manager - Spanish Speaking Preferred

    Location US-MA-Worcester
    Posted Date 3 weeks ago(11/1/2018 4:29 PM)
    Job ID
    # Positions
    Medicare Medicaid Programs
  • 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 fallonhealth.org.

    Brief Summary of Purpose: The Medicare Sales Compliance & Agent Oversight Specialist is responsible for reviewing, promoting, and evaluating the processes for full compliance is achieved with all laws and regulatory requirements to improve both the quality and efficiency of the Medicare Sales Team and its constituents. This role is responsible for conducting compliance audits and working with the appropriate distribution channels, making recommendations for improvement and developing and implementing internal process controls that are capable of preventing and detecting deficiencies. The Medicare Sales Compliance & Agent Oversight Specialist will identify potential areas of compliance vulnerability and risk, and work with department leaders to develop and implement corrective action plans as needed.


    • Develop and maintain working knowledge of Medicare program rules, regulations and requirements. Research, interpret, communicate and answer questions on statutory and regulatory requirements and other CMS guidance.
    • Assist with the development, implementation and oversight of the Medicare Sales department’s compliance Plan, Policies & Procedures, and supporting program documentation.
    • Manage internal process for the receipt, review and internal distribution of all relevant regulatory communications.
    • Track and monitor changes in state and Federal regulatory requirements. Establish repository of all policies and procedures. Provide content expertise to project teams/departments/vendors developing policies and procedures. Contribute to cross-functional projects lead by other departments/distribution channels.
    • Anticipate the impact on the Medicare Sales department of regulatory requirements and advise on risk mitigation strategies that integrate regulatory requirements with business needs.
    • Interpret state and federal regulations to explain governments’ interpretation of and impact on plan offerings and initiatives.
    • Develop, recommend and meet with department managers/directors to implement programs/process to enhance operational efficiencies.
    • Conducts compliance audits throughout the Sales distribution channels, making recommendations for improvement and developing and implementing internal process controls that are capable of preventing and detecting deficiencies.
    • Manage complex compliance activities, including cross-functional projects, data analysis and reporting, and CMS audits and inquiries.
    • Oversee compliance training for all Medicare Sales department staff, contracted agents and brokers.
    • Oversee implementation of Corrective Action Plans and resolution of CTM complaints.
    • Monitor event activities for sales staff and external brokers to ensure CMS compliancy.



    Bachelor's degree or equivalent work experience



    • 5+ year’s related work experience in health care and/or managed care industry
    • Previous experience in an HMO setting and/or regulatory compliance environment strongly preferred.
    • Specialized knowledge of the Medicare risk business strongly preferred
    • Excellent written and oral communication skills


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