Fallon Health

  • Director, Care Services Support

    Location US-MA-Worcester
    Posted Date 1 month ago(11/13/2018 3:33 PM)
    Job ID
    # Positions
    Care Coordination
  • 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 Director will provide leadership and oversight responsibility for the following areas within the health plan: Appeals and Grievances, Credentialing, Payment Policies and clinical trials monitoring. The Director is responsible for a broad set of performance reporting that demonstrate compliance with federal and state requirements pertaining to these areas.


    The Director will act as a resource to staff on regulatory compliance and resolution of issues and will participate in all regulatory and accreditation site visits. The Director will act as the primary point of contact for the organization and staff in regard to policies and procedures.  The Director must present information skillfully to members and providers as well as diplomatically support the policies and benefits of the plan.  The Director will participate in work-group related activities that relate to appeals and grievances, as well as with Payment Policy updates, and coordinate with various internal departments to ensure best practices.


    The Director ensures that:

    • Member appeals and grievances are handled appropriately according to regulatory guidelines and state mandates. Continually monitors the external reviews to ensure that the review organizations agree with the plan’s determinations and the plan complies with the timeframes for1st and 2nd level appeals to be processed.
    • The Medicare Reporting and Auditing function of the Member Appeals Department will be completed timely, and all corrective action plans will be monitored by the supervisors of Member Appeals and Grievances
    • Credentialing activities are performed under the direction of the Manager of Credentialing, and that all contracted providers are in good standing and credentialed according to the plan’s policies.
    • Implementation of medical policies that impact provider payments, pharmacy and therapeutics, cost of care, clinical trials, audits, total medical expense, assessment of new technology and medical affairs.


    Direct Appeals and Grievances Departments

    • Develop and maintain department policies and procedures, training and evaluate job requirements and staff competencies.
    • Advise staff on regulatory issues and monitor compliance of accreditation standards, including federal and state requirements for Medicare and Medicaid as well as Fallon Health benefits and coverage policies, as required.
    • Manage and address department performance for quality, timeliness, and productivity.
    • Identify trends and opportunities for improvement and communicate to internal subject matter experts and committees.
    • Report monthly to committees and upper management on quality and performance metrics and trends.
    • With Supervisors, manage hiring and staff performance evaluations. Ensure staff coverage for business hours and on-call schedules.
    • Communicate to subordinates regularly about interdepartmental and organizational changes and projects.
    • Represent Member Appeals and Grievances in regulatory and accreditation site visits which may include interviews with external surveyors.
    • Manage the maintenance of appeal and grievance files, which includes regular auditing of files to ensure regulatory compliance and compliance with department policies and procedures.
    • Collaborate with various staff regardng new product planning and development relevant to the trends identified with member appeals and grievances.
    • Interact and maintain relationships with trade organizations, employer groups, other health care affiliations and entities on behalf of Fallon Health regarding member appeals and grievances.
    • Provide on-going training to staff on new regulations and policies that impact member appeal and grievance and/or provider appeal processing.
    • Manage and coordinate correspondence with Fallon Health legal and Communications staff, as needed, in response to appeal/grievance requests.

    Direct the Credentialing Department

    • Oversees all aspects of the verification process for provider network incumbents.
    • Develops and implements policies and protocols related to physician, nurse and other employee verifications and ensures that the organization and staff are in accordance with organizational and industry standards.

    Oversee the Implementation

    • Oversees all aspects of the project management and coordination of projects assigned to the implementation manager, including the payment policies.

    Oversee the Policy Implementation and Audit Specialist

    • Oversees the lab audit workgroup, as well as the clinical trials to ensure appropriate cost savings are met.



    Bachelor's degree



    Non Required



    6+ years management experience (health care preferred), excellent written and oral communication skills, excellent organizational and analytical skills, customer service focused, problem-solving ability, and conflict resolution skills. Extensive knowledge of regulatory requirements for the health care/appeal industry, preferably managed care experience.

    Some management and health care experience with excellent written and oral communication, organizational and analytical skills, customer service focused, problem-solving and conflict resolution skills



    QNXT, Outlook, TruCare, Fallon Sharepoint sites, Internet, MS Office, Business Objects, Sequel


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