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

The Manager, Care Management Regulatory Compliance, Accreditation & Audit is accountable for enterprise compliance, accreditation readiness, and audit execution related to Care Management and Care Services operations. This role provides direct people leadership to Care Management Regulatory Managers while personally leading Fallon Health’s accreditation, regulatory audit preparation, and external survey activities across NCQA, CMS, EOHHS/MassHealth, and DOI.

This role serves as the single point of accountability for translating regulatory and accreditation standards into operational practice, ensuring that Care Management documentation, workflows, staff competencies, and quality processes demonstrably meet all applicable requirements. The Manager functions as both a hands-on program leader and a strategic compliance advisor to senior leadership.

Primary Job Responsibilities

A. People Leadership & Oversight of CM Regulatory Staff

• Provides direct supervision, coaching, and performance management for Care Management (CM) Regulatory Managers performing documentation audits, staff competency reviews, and regulatory monitoring
• Establishes standardized audit methodologies, tools, and escalation pathways to ensure consistent regulatory interpretation and application across the CM team
• Reviews audit findings produced by CM Regulatory Managers and ensures timely corrective action plans, follow-up monitoring, and sustained compliance improvement
• Partners with Care Management leadership to address systemic performance gaps, training needs, and workflow redesign identified through audits and root cause analyses
• Ensures staff maintain up-to-date knowledge of Fallon Health products, benefits, Evidence of Coverage, and CM policies
• Ensures the care management division policies and processes are created and updated per corporate guidelines and reflect requirements from CMS, NCQA, and State requirements working in partnership with team and other leaders for accuracy and current state.

 B. Accreditation & Audit Program Leadership

• Personally leads Fallon Health’s accreditation and audit programs, serving as the primary project manager for NCQA surveys, CMS program audits, EOHHS/MassHealth reviews, DOI examinations, and related external oversight activities
• Owns enterprise accreditation calendars, readiness plans, document repositories, and submission timelines, ensuring organizational preparedness at all times
• Directly manages regulatory documentation, narratives, policies, procedures, and evidence submission to external regulatory and accrediting bodies
• Coordinates and oversees onsite and virtual audit activities, including scheduling, staff preparation, real-time issue resolution, and post-audit remediation planning
• Maintains expert-level knowledge of NCQA standards, CMS regulations, MassHealth/EOHHS requirements, and DOI mandates, proactively communicating regulatory changes and operational implications to senior leaders
• Ensures that any NaviCare or Medicare Subcontractor is compliant with all federal and state agency regulatory standards
• Understands the SCO Models of Care and acts as a support and resource for others on the Model

 C. Cross-Functional Regulatory Integration

• Collaborates with leaders across Care Management, Quality Improvement, Utilization Management, Appeals & Grievances, Credentialing, Compliance, Product, and IT to ensure regulatory requirements are operationalized consistently
• Leads cross-functional workgroups to close accreditation gaps, implement regulatory changes, and sustain compliance over time
• Serves as a trusted advisor to executive leadership on regulatory risk, audit readiness, and accreditation strategies

D.  Quality Improvement & Risk Mitigation

• Uses audit and accreditation findings to identify system-level quality improvement opportunities and supports leadership in prioritizing remediation efforts
• Oversees root cause analyses related to regulatory deficiencies and ensure corrective actions are measurable, durable, and aligned with enterprise quality goals
• Supports continuous improvement initiatives tied to member experience, documentation quality, and care management effectiveness

• Bachelor’s degree in health administration, public health, nursing or related health preferred. Master’s degree preferred

Experience: 

• Experience: Minimum of 5- 7 years background in managed care and experience with national accreditation standards, regulatory requirements for Centers for Medicare and Medicaid, and the state of Massachusetts quality mandates. Experience managing NCQA surveys and CMS/MassHealth audits.
• Prior people management experience, including coaching and performance management of regulatory or clinical staff.
• Strong background in Care Management, care coordination, or clinical quality auditing.
• Experience working in a Massachusetts Medicaid and/or Medicare Advantage environment preferred
• Advanced project management and organizational skills
• Exceptional written and verbal communication skills for regulatory submissions
• Ability to translate regulatory standards into practical operational workflows
• Advanced proficiency in Microsoft Office (Excel, Word, PowerPoint); experience with QNXT, TruCare, Business Objects preferred
• Experience developing post audit corrective action plans and working with Program leadership and staff to implement and resolve issues identified in corrective action plans required for all lines of business required
• Experience with developing audit tools, auditing team member performance, and working with staff to improve their performance required
• PC knowledge should include Microsoft software and database

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.