Fallon Health

  • Manager, Care Management ACO

    Location US-MA-Worcester
    Posted Date 1 week ago(12/6/2018 10:06 AM)
    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.


    Responsible for the management of Fallon Health’s care management programs including chronic care management (disease management), complex case management, care management and care coordination. The Manager will work closely with the Manager of Health Promotions, the Director of Care Management, a physician champion and the VP of Quality and Clinical Operations to create a seamless structure and consistent suite of program services between the various member ‘risk levels’.

    The manager will ensure timely coordination of quality healthcare services for; and supervise support and assist in the development, continuous improvement and implementation of the Care Management Program. The Manager of Care Management is responsible for all of the activities related to:

    • The development and implementation of individualized, coordinated care plans,
    • The development and dissemination of required managerial, utilization, productivity and cost/benefit reports,
    • Maintaining appropriate staffing levels for the Teams,
    • The ongoing development and implementation of new strategies, processes, policies and procedures related to the Fallon Care Management program,
    • Compliance with governmental and accrediting agency health plan requirements.
    • Assumption of full responsibility for any project work assigned by the CM DirectorThe Manager should be able to demonstrate knowledge and application of: health promotion, behavior change and population based theories and models; and is familiar with health communication strategies.  


    • Ensures the consistent application of the Fallon Health endorsed clinical practice guidelines for disease management across programs.
    • Seeks to develop strong, evidence-based, data-driven programs based on relevant, measurable, and practical health outcomes.
    • Establishes and measures program success, specifically with regard to health and cost outcomes, including staff productivity and effectiveness
    • Ensures compliance with state, federal and other regulatory bodies such as NCQA.
    • Effectively manages all CM functions to ensure Fallon Health members receive high quality, cost effective care.
    • Hires, orients, supervises, evaluates, counsels and terminates staff that function within the CM Department.
    • Establishes productivity and professional goals with staff and evaluates performance based on these defined goals.
    • Conducts staff meetings on a regular basis.
    • Meets 1:1 with assigned staff on a regular basis.
    • Evaluates staffing and operational needs to ensure that the day-to-day operations of the Unit are carried out in compliance with Departmental and health plan budgetary requirements.
    • Develops, creates, and disseminates reports to effectively manage and continuously improve the CM Program.
    • Creates reports to monitor CM productivity and performance.
    • Performs quality and inter-rater reliability audits on a regular basis and in compliance with the department’s policies and procedures.
    • Collaborates with the CM Director, Medical Director and data analysts to design reports that support the informational requirements of the CM initiatives.
    • Creates and implements CM Policies and Procedures as necessary.
    • Works with the Care Services Directors, Managers and Medical Directors to develop and implement approved CM strategies.
    • Acts as a resource and educator for the CM staff.
    • Coordinates the CM role interdepartmentally, intradepartmentally and with external customers.
    • Delegates and coordinates the activities of the CM Social Workers. 
    • Develops and conducts education / training sessions regarding healthcare services available in the FH system and the community for FH physicians, nurses and ancillary staff.
    • Interfaces and resolves issues with contracted and non-contracted vendors for all ancillary care (e.g., home health, DME, Infusion Therapy, Outpatient Rehab Facilities, etc.) to ensure appropriate quality of care and service is delivered to FCHP members.
    • Participates in research activities to establish benchmarks for care management in the development and implementation of best practices.
    • Strictly observes the HIPPA regulations and the FH policy regarding confidentiality of member information.
    • Performs other responsibilities as assigned by the CM Director
    • Incorporate multicultural diversity and social justice concepts and principles into care services.



    Graduate from an accredited school of nursing or a Bachelors (or advanced) degree in nursing or a health care related field.


    Registered Nurse in Massachusetts; current Massachusetts driver’s license. or a Social Worker (LICSW, LCSW or CSW)


    A minimum of three to five years as a case manager, preferably within the health plan environment, knowledge of government and accreditation requirements, or experience as a manager in the health plan environment in the clinical areas


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