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:
Direct Appeals and Grievances Departments
Direct the Credentialing Department
Oversee the Implementation
Oversee the Policy Implementation and Audit Specialist
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
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