About us:

Fallon Health is a company that cares. We prioritize our members—always—making sure they get the care they need and deserve. Founded in 1977 in Worcester, Massachusetts, Fallon Health delivers equitable, high-quality, coordinated care and is continually rated among the nation’s top health plans for member experience, service, and clinical quality. We believe our individual differences, life experiences, knowledge, self-expression, and unique capabilities allow us to better serve our members. We embrace and encourage differences in age, race, ethnicity, gender identity and expression, physical and mental ability, sexual orientation, socio-economic status, and other characteristics that make people unique. Today, guided by our mission of improving health and inspiring hope, we strive to be the leading provider of government-sponsored health insurance programs—including Medicare, Medicaid, and PACE (Program of All-Inclusive Care for the Elderly)— in the region. Learn more at fallonhealth.org or follow us on Facebook, Twitter and LinkedIn.

Brief Summary of Purpose: 

With general direction from the Director of Quality, the Senior Program Manager ensures that the health plan is compliant with all quality related obligations required by the Centers of Medicare and Medicaid Services (CMS), the Massachusetts Division of Medicaid (MassHealth) or Senior Care Options (Navicare). The Senior Program Manager takes the lead on documentation and reporting to internal and external entities as required by the specific regulators and keeps abreast of changes in the regulatory environment to promote awareness with other senior leaders of the health plan regarding the impact of those revisions to daily operations and procedures. The Senior Program Manager is also consultative to stakeholders on interpreting information received from EOHHS and External Review Organization and providing guidance as needed. He/she interacts with other managers and staff within Fallon Health to facilitate the design and implementation of clinical quality improvement activities and to support HEDIS submissions. In addition, this position is responsible to assist in the hiring, training, and mentoring of quality program managers within the department.

Measure & Calculation (10%)
• Performs data analysis of performance improvement projects (PIP) by collaborating with clinical and data analytics teams to ensure that data needs are identified and incorporated into the PIP process.
• Establishes and defines clear criteria for successful performance improvement project outcomes and shares these criteria with the data analytics team.
Reporting (5%)
• Serves as the ACPP/Fallon Health liaison to EOHHS quality improvement representatives by maintaining regular communication and providing timely responses to all requests for information and/or data relevant to quality activities.
• Manages regulatory Quality projects, including Health Equity deliverables as applicable, for complete and timely submission.
Compliance & Audit (40%)
• Serves as the Project Manager of the External Quality Review Organization quality activities for Medicaid and/or Medicare and coordinates staff responsible for the aspects of the review as well as responses to the external agency.
• Monitors all quality activities related to CMS and MA EOHHS requirements, ensuring compliance with all such activities, and maintaining accountability for the execution and performance of all program requirements.
• Maintains an active role in Fallon Health’s overall quality services structure, specifically supports the CMS and MA EOHHS quality programs.
• Primary Fallon Health representative in the quality workgroups and other meetings facilitated by EOHHS or other EOHHS contractors.
• Submits to the regulator required annual QM/QI Strategic Work Plan, Work Plan evaluations, Quality Improvement projects, etc. that shall include planned clinical and non-clinical initiatives.
• Collaborates with the Health Equity Program Manager to meet the Health Equity requirements of the ACO contract.
• Develops and implements policies and procedures that ensure compliance with legal and other external regulations/requirements and supports the continuous improvement of the quality of service provided by the department. As applicable, provides support for process and operational improvements related to clinical initiatives.
• Coordinates the annual Appendix Q Quality Performance Measurement project in its entirety for the Medicaid ACOs.
• Ensures the privacy and security of PHI (Protected Health Information) as outlined in Fallon Health’s policies and procedures related to HIPAA compliance.
Improvement (45%)
• Participates in the development of the annual Quality Work Plan and Work Plan Evaluation.
• Chairs the Quality Workgroups with all ACO partners to review quality metric performance and quality service-related activities.
• Leads and motivates provider partners to identify opportunities for improvement and implement quality improvement projects by using data and fostering collaboration.
• Manages the development and reporting of clinical quality initiatives for Medicaid Performance Improvement Projects to the designated External Quality Review Organization as required  by EOHHS.
• Represents the Quality Department and Fallon’s ACPP as an active participant on the Health Equity Workgroup by providing feedback on the ACO Quality/Health Equity work as it relates to Fallon’s Health Equity Strategic Plan.
• Collaborates with applicable vendors to facilitate the exchange of data, development and approval of collateral program materials, and outreach to network providers to support quality improvements.
• Works collectively with internal and external managers and Quality Programs staff, including medical directors and administrators, to monitor and interpret data to identify and act upon actionable opportunities that result in continuous quality improvements and positive outcomes for Plan members and network providers.

Education

Bachelor’s degree in business, health administration, public health, nursing, or related health field required. Master’s degree in a health related field preferred.

License/Certifcations

Nursing preferred

Experience

• Minimum of 5 years’ experience within a health care/managed care setting directing quality management or care management programs with an emphasis on measurable outcomes.
• Knowledge of quality improvement processes, statistical analysis, and outcomes measurements.
• Demonstrated successful organizational and communication skills, creativity, critical thinking, problem-solving skills, and the ability to self-manage and prioritize.
• Experience leading teams effectively to ensure team collaboration and successful project outcomes
• Experience with data analysis and health research with a quantitative focus.
• Experience and or knowledge of HEDIS/CMS/Quality preferred
• Strong communication (verbal and written) and critical thinking skills
• Strong interpersonal skills with the ability to build productive relationships with external and internal stakeholders
• Strong organizational skills with attention to detail
• Demostrated problem solving skills
• Ability to manage time effectively and meet deliverables
• Ability to work with minimal supervision and as part of a team
• Report writing skills and excellent presentation skills
• Ability to work with computer and Microsoft Office Suite products

Fallon Health provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.