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Job Locations US-NY-Amherst, NY
Posted Date 15 hours ago(5/26/2020 3:59 PM)
Fallon Health Weinberg is a partnership between Fallon Health of Massachusetts and Weinberg Campus of Erie County, New York. Fallon Health Weinberg offers a Program of All-Inclusive Care for the Elderly (PACE) and a Managed Long Term Care (MLTC) plan to serve the health needs of dual-eligible residents of the Western New York counties of Erie and Niagara. Fallon Health Weinberg expands the choices that residents of Erie and Niagara Counties have when it comes to high-quality, affordable health care.   Founded in 1977, Fallon Health provides health care services designed to meet the unique and changing needs of all they serve. It consistently ranks as one of the nation's highest-rated health plans, according to the National Committee for Quality Assurance (NCQA).   The primary responsibility of the Outreach Coordinator is to maximize marketing efforts to generate referrals in order to meet enrollment goals that assists in the growth and retention of membership.
Job ID
5989
Product Line
Fallon Health Weinberg
Job Locations US-NY-Amherst, NY
Posted Date 15 hours ago(5/26/2020 4:00 PM)
Fallon Health Weinberg is a partnership between Fallon Health of Massachusetts and Weinberg Campus of Erie County, New York. Fallon Health Weinberg offers a Program of All-Inclusive Care for the Elderly (PACE) and a Managed Long Term Care (MLTC) plan to serve the health needs of dual-eligible residents of the Western New York counties of Erie and Niagara. Fallon Health Weinberg expands the choices that residents of Erie and Niagara Counties have when it comes to high-quality, affordable health care.   Founded in 1977, Fallon Health provides health care services designed to meet the unique and changing needs of all they serve. It consistently ranks as one of the nation's highest-rated health plans, according to the National Committee for Quality Assurance (NCQA).* Fallon Health coordinates care with its Senior Care Options/Special Needs Plan for dual-eligible people who are 65 and older. Fallon Health has operated a PACE program in Massachusetts for more than 20 years and is the largest PACE program in New England and sixth largest nationally.**   Weinberg Campus has been providing needed services to the elderly for more than 100 years, through both community-based programs and nursing facility care. It is a renowned geriatric education and training institution offering the widest range of housing and care options available on one campus. The two parent companies, Fallon Health and Weinberg Campus, have demonstrated consistent commitment to providing an array of solutions that make high-quality, integrated and affordable care more accessible to the poor, disabled and senior populations within the communities they serve.   To provide the members of the managed long term care plan with  assistance as needed with benefits, authorizations, and communications.
Job ID
5988
Product Line
Fallon Health Weinberg
Job Locations US-MA-Lowell
Posted Date 6 days ago(5/21/2020 4:47 PM)
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. About Summit ElderCare: Fallon Health operates the largest Program of All-Inclusive Care for the Elderly (PACE) in New England and the fifth largest in the country. Called Summit ElderCare, Fallon’s PACE helps provide older adults and their caregivers with a welcome alternative to nursing home care. Participants in Summit ElderCare have access to comprehensive medical services and social support at a Summit ElderCare site while they keep the independence of living in their own homes and communities. Position Overview: The clinical assistant performs clinical and administrative duties under the direction of the Clinical Nurse Manager, assists the MD/DO, NP and/or RN in administering care and treatment to participants including but not limited to phlebotomy and EKG in an expeditious, courteous and professional manner, facilitating a smooth flow of healthcare practices, providing basic and direct care to participants as directed, and ensuring a good patient care experience in the PACE clinic.  
Job ID
5987
Product Line
Summit ElderCare
Job Locations US-MA-Worcester
Posted Date 1 week ago(5/19/2020 11:25 AM)
Fantastic Call Center & Advancement Opportunities in Health Care!   The Opportunity:   We are currently hiring for a 9:30 am - 6:00 pm shift with one evening per month and occasional weekends between October - March.   It’s an exciting time to join Fallon Health as we experience growth and expansion with new services and products. There are many great opportunities within our organization starting with joining our Member Services team. Member Services offers a very unique opportunity to interact with nearly every facet of the FCHP organization including our products, services, functions, and people.    Among the most rewarding and fulfilling parts of working on this team is representing Fallon Health as the face of the organization; the single point of contact for our valued providers and members. Think of yourself as an FCHP brand and membership ambassador. As a representative of Fallon Health, you will be an advocate to members reaching out for support; providing this highly valued service fielding calls and consultatively troubleshooting inquiries, you will be solving their needs and concerns.   In addition to the diverse responsibilities outlined below, a spot on this team also represents one of the best places to grow your career.  With demonstrated initiative and strong performance, you will gain exposure across a multitude of functions and endless opportunities for advancement. Member Services has proven to be a launching  pad of development that has translated into long term careers with advancement opportunities throughout the company in a number of different key area’s such as; Sales and Marketing, Provider Relations, Care Services, Pharmacy and other functions of the operation.             As a brand champion and valued member ambassador you will get extensive training and support through a skill based progression training program that includes a blended learning curriculum and personalized coaching plan.  We are always looking for top talent in these roles so feel free to pass this along to friends, family and colleagues that you think qualify.     
Job ID
5986
Product Line
FCHP
Job Locations US-MA-Worcester
Posted Date 2 weeks ago(5/12/2020 12:41 PM)
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: The Coding and Documentation Integrity Specialists II’s primary responsibility is to support the provider appeals department. The Coding and Documentation Integrity Specialists II’s job will focus on coding and documentation support for provider appeals department, assisting with E/M audits. The Coding and Documentation Integrity Specialist II will review medical record details and documentation observations from multiple chart sources to validate E/M level of service, medical necessity and payer policy guidelines. The Coding and Documentation Specialist II must demonstrate the ability to work with the Coding and Documentation Integrity team effectively and efficiently. Light travel involved
Job ID
5984
Product Line
FCHP
Job Locations US-MA-Worcester
Posted Date 2 weeks ago(5/12/2020 12:18 PM)
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: The Coding and Documentation Integrity Specialists I’s primary responsibility is to support multiple LOBs, including claims, provider contracting, provider appeals, FWA, SIU. The Coding and Documentation Integrity Specialists I’s job will focus on coding and documentation support for medical record chart reviews. The Coding and Documentation Integrity Specialist I will review medical record details and documentation observations from multiple chart sources to validate E/M level of service. The Coding and Documentation Specialist I must demonstrate the ability to work with the Coding and Documentation Integrity team effectively and efficiently. Light travel involved.
Job ID
5983
Product Line
FCHP
Job Locations US-MA-Worcester
Posted Date 2 weeks ago(5/11/2020 11:09 AM)
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 vendor relationship manager is responsible to handle multiple healthcare vendor relationships as the main point of contact, managing the day to day operational work, associated projects and instituting and monitoring operational metrics. This position will collaborate with various internal departments and program/product stakeholders at all levels to support the governance of the vendor contract relationships this will include but not be limited to evaluating and prioritizing multiple requests put forth by internal departments/stakeholders, cadence of joint operating meetings, potential change in scope of vendor contracts and problem resolution and corrective action plans. Key interface between Fallon Health Regulatory Compliance and healthcare vendor and to ensure healthcare vendor is in compliance with federal and state requirements.
Job ID
5982
Product Line
FCHP
Job Locations US-MA-Worcester
Posted Date 2 weeks ago(5/11/2020 10:35 AM)
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. About NaviCare: Fallon Health is a leader in providing senior care solutions such as NaviCare, a Medicare Advantage Special Needs Plan and Senior Care Options program. Navicare integrates care for adults age 65 and older who are dually eligible for both Medicare and MassHealth Standard. A personalized primary care team manages and coordinates the NaviCare member’s health care by working with each member, the member’s family and health care providers to ensure the best possible outcomes.   Brief Summary of Purpose: The Nurse Case Manager (NCM) Internal is focused on care coordination and improving quality of care and access to services for our ACO Fallon members in the Cancer Program. The NCM Internal supports the Clinical Integration Team in a role that does not routinely complete in-home/facility face-to-face visits with members and/or providers. Responsibilities include telephonically assessing a Members clinical/functional status to identify ongoing special conditions and providing education. Develops and implements an individualized, coordinated care plan in collaboration with the member and Primary Care Provider and/or specialist and other community partners to ensure quality outcomes in a cost effective way. Communicates with member/family/caregiver(s) in accordance with frequency of Case Management contact guidelines. Works collaboratively with other members of the Clinical Integration Team including the ACO, to provide overall case management, care plan oversight, and care coordination for our members.  
Job ID
5979
Product Line
FCHP
Job Locations US-MA-Worcester
Posted Date 1 month ago(4/28/2020 12:31 PM)
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. Summary: The Fallon Health authorization process is an essential function to Fallon Health’s compliance with CMS regulations, NCQA standards, regulatory requirements, and customer expectations. The Business Process Coordinator II supports these functions through authorization discrepancy and reconciliation quality analysis. This process assures the end result of processing all services in accordance with member’s rights as outlined in the Member Handbook/Evidence of Coverage, authorization policies, procedures and benefit design across all of Care Services programs across all product lines (including SCO, PACE, Commercial, Medicare, Medicaid and Dual Eligible products, etc.). Utilizing their extensive knowledge of regulatory guidelines, UM protocols, claims processing guidelines and benefit design and system configuration, the Business Process Coordinator II is responsible to support the review and response relating to authorization and claim discrepancies reported within the TruCare and QNXT systems. The Business Process Coordinator is responsible for: - Researching and reconciling authorization and claim discrepancies - Identifying trends and opportunities for reeducation and process improvement related to the initial authorization data entry and claims processing - Ensuring all Care Services business requirements are accurately followed - Making necessary modifications to authorizations; creating new authorizations as appropriate to adjudicate claims to resolve discrepancies - Assisting in reconciliation of authorization template configuration as it supports claims adjudication - Assisting in designing, developing, and maintaining TruCare authorization entry education materials for Care Services Division - The Business Process Coordinator II is the link between the authorization / claims process, assuring that the member, provider and Fallon Health complete an effective circle of servicing the member from request through rendering payment by driving change through collaboration with all Care Services departments to achieve quality data entry of authorizations on a consistent basis.
Job ID
5978
Product Line
FCHP
Job Locations US-MA-Worcester
Posted Date 1 month ago(4/27/2020 3:10 PM)
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. Summary of Purpose: Responsible for the coordination and timely completion of provider appeals. Serves as a liaison between FCHP and contracted and non-contracted providers with appeals regarding filing limit appeals, claim denials, claim payment, retrospective referrals, administrative inpatient days and other issues for which the provider is liable. This does not include appeals filed by providers on behalf of an FCHP member.
Job ID
5976
Product Line
FCHP
Job Locations US-MA-Worcester
Posted Date 1 month ago(4/27/2020 5:12 PM)
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 the only health plan in Massachusetts to have been awarded “Excellent” Accreditation by the National Committee for Quality Assurance for its HMO, Medicare Advantage and Medicaid products. For more information, visit www.fallonhealth.org.   Position Overview: Under the direction of the Manager of Prior Authorization, communicates with contracted and non-contracted facilities/agencies/providers to collect pertinent prior authorization request data and disseminates information to the Authorization Coordinators. Additionally, supports the authorization process by receiving incoming faxed/mailed/emailed/etc. requests and initiates entry of service request shells into core system -TruCare. Responsible for incoming calls from the multiple ACD lines for the UM department addressing and/or referring customer (provider/member) calls/inquiries, provide direction regarding Plan policies, procedures and when applicable, benefit information. Work in conjunction with other Fallon Health departments to assist in processing authorization information in order to facilitate the member’s medical services or the providers’ claims. Interprets and triages information to ensure appropriate action is initiated to meet regulatory bodies’ standards and to maintain the quality and timeliness of the authorization process.  
Job ID
5972
Product Line
FCHP
Job Locations US-MA-Worcester
Posted Date 2 weeks ago(5/11/2020 10:40 AM)
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 www.fallonhealth.org.   Brief Summary of Positions: The Medicare Compliance & Regulatory Affairs Associate acts as a regulatory resource to clarify, monitor, and research regulatory requirements, provides proactive compliance monitoring and assessments with regards to key initiatives and increasing compliance requirements, collaborates with business areas and vendors to manage corrective action processes when needed, and supports CMS audits. This includes changes that impact the structure and operation of Medicare Advantage, PACE and other Medicare products as well as Medicare initial and expansion applications, RFIs, RFAs, and compliance versight. Develops legal arguments for Medicare Programs as needed. A component of the position is dedicated to compliance management of Medicare required reporting in accordance to the state and federal requirements. Additionally, this position includes Fallon Policy and Procedure Librarian responsibilities that include sending annual review policy and procedure reminders to business areas, providing education on the development of and uploading of final policies and procedures.
Job ID
5969
Product Line
FCHP
Job Locations US-MA-Worcester
Posted Date 2 months ago(4/6/2020 1:26 PM)
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. Summary: Serve as primary liaison between Fallon Health and all contracted and limited non-contracted physicians/providers, hospitals and ancillary providers within an assigned territory.  Monitor provider business operations to ensure compliance with Fallon Health's documented standards, policy and procedures and government regulations.
Job ID
5968
Product Line
FCHP
Job Locations US-MA-Worcester
Posted Date 2 months ago(4/1/2020 9:33 AM)
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 www.fallonhealth.org.   Brief Summary of Purpose: Responsible for reviewing prescribed medications performing clinical and drug utilization reviews and clinical/economic evaluation of therapies and writing criteria sets for medications that have a prior authorization attached to them. Responsible for designing and implementing clinical pharmacy programs and initiatives primarily for the PACE program. Position may require implementing programs and interventions for commercial and Medicaid products.
Job ID
5967
Product Line
Summit ElderCare
Job Locations US-MA-Worcester
Posted Date 2 months ago(3/25/2020 2:52 PM)
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 www.fallonhealth.org.   The Business Intelligence (BI) Consultant works closely with business and IT teams to turn data into critical information and knowledge that can be used to make sound business decisions. They partner with the business to determine business needs, priorities, define KPI’s and establish BI strategy. This includes the design, and implementation of dashboards, reports and other various BI applications.   BI Consultants develop and implement BI solutions that enable the business to use data as an analytical tool, displaying the information in new forms for the purpose of analysis, exploration, prescriptive/predictive analytics and reporting. Key to this role is establishing the BI enterprise architecture and BI design standards that will support the Fallon Health BI strategy. The BI Consultant plays an important role in advancing the Fallon Health BI maturity path by providing the necessary consultation, education, and capabilities in order to meet our corporate and strategic goals.
Job ID
5962
Product Line
FCHP
Job Locations US-MA-Worcester
Posted Date 2 months ago(3/25/2020 2:17 PM)
  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 www.fallonhealth.org.   Brief summary of purpose: Responsible for requirements gathering, designing, developing, testing, delivering and maintaining system integration, data integration, and web application/service solutions based on business requirements, making use of existing technical capabilities and services in the organization.. Align new solutions to the current architectural principles regarding standards and integration in the organization. Work collaboratively within and across development and project teams in a fast-paced work environment.   -  
Job ID
5961
Product Line
FCHP
Job Locations US-MA-Springfield
Posted Date 2 months ago(3/23/2020 9:54 AM)
SUMMIT ELDERCARE (www.summiteldercare.org) Fallon Health’s – Summit Elder Care program one of  the largest PACE programs (Program of All-Inclusive Care for the Elderly) in the country and the very first PACE program in the nation to be associated with a Health Plan. Summit ElderCare currently already serves residents of Hampden County, Worcester County, and the communities of Easthampton, Granby, Hudson, Marlborough, Southampton and South Hadley. We help give elderly adults and their caregivers an innovative choice in health care as a welcome alternative to nursing home care. Participants in Summit ElderCare have access to most medical services through a Summit ElderCare site while they keep living in their own homes and communities.   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 www.fallonhealth.org.   Position Overview: Provides primary health care to Summit ElderCare program participants focusing on disease prevention and/or stabilization, and management of chronic and episodic illness in collaboration with the program’s primary care physician providers. Works with the interdisciplinary team to establish realistic and measurable goals and to develop and manage individualized plans of care for program participants.
Job ID
5957
Product Line
Summit ElderCare
Job Locations US-MA-Quincy
Posted Date 1 month ago(4/13/2020 12:45 PM)
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 www.fallonhealth.org.   About NaviCare: Fallon Health is a leader in providing senior care solutions such as NaviCare, a Medicare Advantage Special Needs Plan and Senior Care Options program. Navicare integrates care for adults age 65 and older who are dually eligible for both Medicare and MassHealth Standard. A personalized primary care team manages and coordinates the NaviCare member’s health care by working with each member, the member’s family and health care providers to ensure the best possible outcomes.   Position Overview: This position requires that the Account Executive achieves personal referral and outreach goals for the NaviCare program. Manages a territory and group of referral source accounts, providing regular follow up and overcoming barriers with each account to meet enrollment goals.
Job ID
5956
Product Line
NaviCare
Job Locations US-MA-Worcester
Posted Date 2 months ago(3/19/2020 1:12 PM)
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. Position Summary: The Electronic Data Interchange (EDI) Coordinator is an exempt position and a “key-player” on the operations team. The EDI Coordinator is responsible to facilitate the electronic flow of data from both internal and external customers. Our goal is to increase the volume of electronically submitted claims and our Auto-Adjudication of Claims. This includes oversight of the EDI Process, working directly with our trading partners and government agencies to enhance the Secure and HIPAA Compliant, electronic flow of information. The work involves tracking of incoming EDI files, monitoring and researching unsuccessful transmissions, recognizing patterns, identifying issues, and building solutions to improve Fallon Health’s operations.    
Job ID
5955
Product Line
FCHP
Job Locations US-MA-Springfield
Posted Date 1 month ago(4/13/2020 12:44 PM)
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 www.fallonhealth.org.   About NaviCare: Fallon Health is a leader in providing senior care solutions such as NaviCare, a Medicare Advantage Special Needs Plan and Senior Care Options program. Navicare integrates care for adults age 65 and older who are dually eligible for both Medicare and MassHealth Standard. A personalized primary care team manages and coordinates the NaviCare member’s health care by working with each member, the member’s family and health care providers to ensure the best possible outcomes.   Position Overview: This position requires that the Account Executive achieves personal referral and outreach goals for the NaviCare program. Manages a territory and group of referral source accounts, providing regular follow up and overcoming barriers with each account to meet enrollment goals.
Job ID
5947
Product Line
NaviCare
Job Locations US-NY-Amherst, NY
Posted Date 2 weeks ago(5/15/2020 2:39 PM)
Fallon Health Weinbergis a partnership between Fallon Health of Massachusetts and Weinberg Campus of Erie County, New York. Fallon Health Weinberg offers a Program of All-Inclusive Care for the Elderly (PACE) and a Managed Long Term Care (MLTC) plan to serve the health needs of dual-eligible residents of the Western New York counties of Erie and Niagara. Fallon Health Weinberg expands the choices that residents of Erie and Niagara Counties have when it comes to high-quality, affordable health care. Founded in 1977, Fallon Health provides health care services designed to meet the unique and changing needs of all they serve. It consistently ranks as one of the nation's highest-rated health plans, according to the National Committee for Quality Assurance (NCQA).* Fallon Health coordinates care with its Senior Care Options/Special Needs Plan for dual-eligible people who are 65 and older. Fallon Health has operated a PACE program in Massachusetts for more than 20 years and is the largest PACE program in New England and sixth largest nationally.**   Weinberg Campus has been providing needed services to the elderly for more than 100 years, through both community-based programs and nursing facility care. It is a renowned geriatric education and training institution offering the widest range of housing and care options available on one campus. The two parent companies, Fallon Health and Weinberg Campus, have demonstrated consistent commitment to providing an array of solutions that make high-quality, integrated and affordable care more accessible to the poor, disabled and senior populations within the communities they serve.   Fallon Health Weinberg in Amherst, NY is currently seeking an experienced RN Nurse Care Manager for our quickly expanding MLTC program. This is a full time day, Monday - Friday, RN nursing position. At Fallon Health Weinberg, you’ll find a competitive salary, comprehensive benefits and a stimulating, collaborative culture. Our dedicated professionals truly work as a TEAM, united by compassion for the people we support, each contributing to our innovative approach to health care. Fallon Health Weinberg is increasing access to high-quality, person-centered, cost-effective health care programs for older individuals who require supportive services due to long-term health needs but want to remain living independently in the Buffalo NY community. We currently offer three plans to provide care and care coordination for people in their homes: - Managed Long Term Care Plan (MLTC) - PACE: Program of All Inclusive Care for the Elderly. Under the direction of the Director of Clinical Services (DCS), the FHW Care Manager (CM) is able to work both independently and collaboratively with other members of the FHW Program Primary Care Team. The CM follows established departmental policies and standards for timely completion of assigned work.   Problems lacking clear precedent are reviewed with DCS or her/his designee prior to taking action.   The CM presents a clear definition of problem(s) when reviewing with the Primary Care Team, Primary Care Physician and/or Medical Director.   The FHW Care Manager (CM) assesses a Members clinical/functional status and develops a plan to coordinate a continuum of care consistent with the Members health care needs and/or goals. The Individualized Care Plan (ICP) supports the Member attaining and/or maintaining an optimal functional status. The CM is an active participant in the Members Interdisciplinary Care Team (ICT) and is an advocate for the Member.   The CM is actively involved with the Member at times of care transition, including but not limited to planned and unplanned admissions, and works in conjunction with the members team to ensure care plan communication between all providers and members of the ICT.   The CM coordinates care between multiple medical and Primary Care Team Providers. The CM is able to identify services, care delivery settings, and recommends alternatives where appropriate.    The CM monitors the care and provides consistent feedback to team on progress. The CM collaborates and works with all members of the Interdisciplinary Care Team and, when appropriate, the FHW care manager will work with Acute care hospitals, rehab facilities and skilled nursing facilities to ensure an effective care plan to meet member care needs.  The CM may attend Facility Discharge Planning Rounds and works to ensure a smooth discharge and transition as appropriate    
Job ID
5943
Product Line
Fallon Health Weinberg
Job Locations US-MA-Worcester
Posted Date 1 month ago(4/16/2020 4:31 PM)
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 Project Manager - Strategic Business Development & Planning will initiate efforts and facilitate cross functional activity required to support strategic planning.  S/he will work closely with the executive team to develop, monitor and adjust Fallon Health’s strategic plan and organizational priorities, and to develop the next iteration of the corporate strategy.  S/he will lead or support efforts to develop, vet, and implement various business development initiatives with current and emerging external partners.  S/he will work closely with peers in other functional areas to transition initiatives into the respective function.   
Job ID
5942
Product Line
FCHP
Job Locations US-MA-Worcester
Posted Date 3 months ago(3/2/2020 5:21 PM)
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. About Summit ElderCare: Fallon Health operates the largest Program of All-Inclusive Care for the Elderly (PACE) in New England and the fifth largest in the country. Called Summit ElderCare, Fallon’s PACE helps provide older adults and their caregivers with a welcome alternative to nursing home care. Participants in Summit ElderCare have access to comprehensive medical services and social support at a Summit ElderCare site while they keep the independence of living in their own homes and communities. Position Purpose: Functions as a member of the PACE Interdisciplinary Team and provides social work services, support and counseling to participants, families and other caregivers. Supervises and directs the Social Work Department in accordance with accepted social work practice. Collaborates with IDT and SE management team to ensure utilization and MLR targets are met.
Job ID
5938
Product Line
Summit ElderCare
Job Locations US-MA-Worcester
Posted Date 1 month ago(4/13/2020 3:56 PM)
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 ACO Account Executive is responsible for building and maintaining relationships with Fallon’s ACO Provider Partners. This role will oversee the ACO Provider Partner’s Governance Structure and function as liaison for the Provider Partners as necessary. The ACO Account Executive will partner closely with the ACO Program Manager IV to resolve any operational issues raised by Provider Partners. The ACO Account Executive will also partner closely with the Fallon Contract Managers responsible for the overseeing the 3 ACO contracts.
Job ID
5913
Product Line
FCHP
Job Locations US-MA-Worcester
Posted Date 3 months ago(2/25/2020 4:23 PM)
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  www.fallonhealth.org.   Position Purpose:   Proposal Management: Develops proposals, bids, quotations, or other documents describing organizational products and services in response to requests from prospective clients. Collaborates with members of the sales, marketing, finance, legal, or product teams to ensure proposal content is complete, accurate, and timely. Is responsible for developing responses to the most complex or high-value inquiries including organizational procurement activities for Mass Health, Senior Care Options program, The Group Insurance Commission, and The Connector QHP.  Responsible for the oversight and maintenance of the corporate content for efficiency and integrity.   Market Intelligence: Leads data gathering for Fallon’s competitive intelligence activities This person will be the internal expert in competitors’ products, pricing, membership, and financial performance across product lines (commercial, Medicare, Medicaid).  In addition, he/she will be expected to research and assess national trends in the healthcare industry as well as national competitor’s offerings, strategies, strengths and weaknesses.  This position will be responsible for assisting the Director with preparing regular environmental assessments that include extensive detail on competitors, industry trends and important regulatory insights.   Product Development: Responsible for assisting the commercial and Medicare product managers with a variety of projects.  This will include but not be limited to: - helping to QC product materials, filings with the Connector and CMS - leading smaller product management initiatives assisting in annual commercial and Medicare bids and vendor management.
Job ID
5912
Product Line
FCHP
Job Locations US-MA-Worcester
Posted Date 2 months ago(4/9/2020 8:47 AM)
Fallon Health and UltraBenefits are considered essential employers and we remain in full operation during these challenging times with the COVID-19 pandemic. To that end, we are continuing to recruit and hire for this role and we hope to hear from you.    THE OPPORTUNITY: UltraBenefits (UB) and its subsidiary Group Insurance Service Center (GISC) are two very reputable and successful Massachusetts based TPA organizations and both are business entities under Fallon Health. This key leadership role will have oversight for new business and retention for both TPA organizations. Although both firms are profitable we feel there’s greater opportunity for growth and expansion and this key new leader will have the autonomy to make a great impact and taking sales, membership and revenue to the next level.   UB is based in Worcester, MA and GISC is in Pembroke, MA and we are open-minded on where the new VP lives within the state. They will need to spend time at both locations.       About UltraBenefits UltraBenefits' purpose is to provide employers with innovative solutions in managing their employee benefit plan costs and exceed their expectations for customer service. Our Core Values; Customers must come first, Honesty and integrity are essential, High quality is a requirement, Stimulate individual initiative and personal growth, Cost-effective operating environment serves the customers, "Work hard and keep it fun". Our products offering include; Dental/medical administration, Flexible Spending Accounts, Healthcare Reimbursement Arrangements          
Job ID
5905
Product Line
FCHP
Job Locations US-MA-Worcester
Posted Date 3 weeks ago(5/6/2020 8:41 AM)
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: Under the direction of the Supervisor or Manager, the Enrollment & Billing Operations Representative I supports Fallon Health’s mission, vision and values by providing and maintaining timely and accurate enrollment and billing information. Documents pertinent information enabling tracking of group/subscriber/member and eligibility and adheres to internal and external SLA’s. With speed, accuracy, and integrity, ensures that enrollee data for Medicare Advantage, Medicare Supplement, NaviCare, Summit Elder Care, Fallon Health Weinberg and any future regulatory products is entered into Fallon Health’s core system. Completes work accurately and timely to remain in compliance with DOI, CMS and EOHHS regulations. Appropriately escalates concerns when necessary and follows issues through to closure. Reviews problems not clearly defined by written directives or instructions with the Enrollment & Billing Operations Representative III, Enrollment & Billing Operations Supervisor, or Enrollment & Billing Operations Manager to determine course of action. The Enrollment & Billing Operations Representative I collaborates effectively with co-workers and other departments to ensure quality service to our internal and external customers. Maintains a positive approach to issues and concerns as they arise, and works to identify and recommend process improvements to his/her direct supervisor/manager. Pre-requisites for success in this position include: Strong verbal & written communication skills including demonstrated excellence in telephone communication skills; strong organizational skills, computer skills. Performs all functions necessary to maintain accurate subsidiary accounts receivable, and ensures accuracy of premium bills. Reconciles employer group bills to group payment listings or direct pay member bills, and appropriately researches. Reviews monthly Accounts Receivable Summary and Aged Trial Balance to identify problems with payments, etc.   Handles confidential customer information. Knowledgeable of plan policies, protocols, and procedures. Requires ability to work in a fast-paced environment with multi-disciplined staff. Consistently follows through on issue resolution. Strong multitasking abilities are essential along with taking accountability and understanding job functions can change based upon the business need. Initiates self-development via available company and industry educational opportunities   Enrollment & Billing Operations Representative is responsible for enrollment and billing maintenance, adhering to daily, weekly and monthly schedules and administrative related tasks.  
Job ID
5900
Product Line
FCHP
Job Locations US-MA-Springfield
Posted Date 4 months ago(1/24/2020 3:37 PM)
SUMMIT ELDERCARE (www.summiteldercare.org) Fallon Health’s – Summit Elder Care program one of  the largest PACE programs (Program of All-Inclusive Care for the Elderly) in the country and the very first PACE program in the nation to be associated with a Health Plan. As a Physician in this field, this is a great alternative for Primary Care and Internal Medicine  doctors who are tired of being tied to high volume and RVU’s. We have a quality over quantity approach and patient load is under 10 on most days.   Summit ElderCare currently already serves residents of Hampden County, Worcester County, and the communities of Easthampton, Granby, Hudson, Marlborough, Southampton and South Hadley. We help give elderly adults and their caregivers an innovative choice in health care as a welcome alternative to nursing home care. Participants in Summit ElderCare have access to most medical services through a Summit ElderCare site while they keep living in their own homes and communities. Summit ElderCare provides individualized quality care by a team of geriatric care professionals who work together with participants and caregivers to address each individual's specific needs. This Interdisciplinary team of professionals is an essential component of the Summit ElderCare PACE program and uses a collaborative approach to care FALLON HEALTH (www.fchp.org)   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.  
Job ID
5879
Product Line
Summit ElderCare
Job Locations US-MA-Worcester
Posted Date 4 months ago(1/23/2020 4:33 PM)
WHAT IS A “PACE” PROGRAM? Programs of All-Inclusive Care for the Elderly (PACE) The PACE Model of Care is centered on the belief that it is better for the well-being of seniors with chronic care needs and their families to be served in the community whenever possible. These are individuals who are age 55 or older, certified by their state to need nursing home care, able to live safely in the community at the time of enrollment, and live in a PACE service area.   THE OPPORTUNITY: Fallon Health’s Summit ElderCare operates 6 PACE programs around Massachusetts and our growth finds us very excited to bring a new physician leader on to the team. This role is considered the second in command and part of the future and growth of Summit ElderCare and you will enjoy being partnered very closely with our PACE Medical Director. You will be intimately involved in every facet of our Summit ElderCare business including (but not limited to); Manage and develop staff, Utilization and Quality Management and regulatory Compliance, Participant care.   ABOUT SUMMIT ELDERCARE: Summit ElderCare, offered by Fallon Health, is the only program of its kind in Central Massachusetts and is one of eight PACE programs in the State. Currently there are 130 PACE Organizations nationwide across 31 states operating 263 PACE centers. Summit ElderCare provides a combination of medical, social and insurance services using an interdisciplinary team approach to help older adults avoid nursing home placement. The program offers outpatient medical care, social day programming, home care and comprehensive insurance coverage with no co-payments or paperwork for participants. Our physicians and nurse practitioners are able to provide care for the frail elder not available in any other setting. Our comprehensive program is not constrained by the usual insurance company rules and benefit limitations and we have the capacity to offer services that are not often covered by other plans.   The physicians and nurse practitioners have flexibility to devote as much time as needed for the clinical and social needs of our participants and their caregivers to provide individualized quality care by a team of geriatric care professionals who work together with participants and caregivers to address each individual's specific needs. This team of professionals is an essential component of the Summit ElderCare PACE program.   The team uses a collaborative approach to care planning and is called the Interdisciplinary Team (IDT). The IDT is comprised of Providers (MD/DO and NP), Nurses, Social Workers, Physical and Occupational Therapists, Dieticians, Health Aides, Recreation staff, Home Care and Transportation Coordinators and Site Administrator. This approach to care is the gold standard for complex and frail older adults who wish to avoid nursing home placement.  
Job ID
5876
Product Line
Summit ElderCare
Job Locations US-MA-Worcester
Posted Date 1 month ago(4/16/2020 4:31 PM)
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: Responsible for the overall improvement of the quality, completeness and accuracy of medical record documentation through interaction with physicians and other business partners. Ensures clinical documentation reflects the level of service, severity of illness, risk of mortality is complete, accurate and successfully facilitates the accurate representation of a patient’s medical records that translates into coded data.
Job ID
5868
Product Line
FCHP
Job Locations US-MA-Worcester
Posted Date 1 month ago(4/16/2020 4:29 PM)
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: Summary: This position will contribute to an important strategic initiative of Fallon Health in improving the quality of care of our members. With supervision from the Senior Manager Accreditation, the quality Improvement nurse will be responsible for carrying out the assigned quality improvement initiatives such as the development and implementation of member outreach strategies, and the acquiring of clinical quality data analysis, and presentation to internal and external customers. Other responsibilities include medical record data abstraction and the development of clinical quality initiatives. The nurse will provide clinical expertise and support for departmental initiatives and the Quality Services program structure.
Job ID
5867
Product Line
FCHP
Job Locations US-MA-Worcester
Posted Date 6 months ago(11/21/2019 5:30 PM)
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 Chart Review Specialist primary responsibility is to review, analyze and report on FCHP patient charts for the purpose of validating regulatory Risk Adjustment scores. The Chart Review Specialist will collect diagnostic details and documentation observations from multiple chart sources to validate diagnostic profiles.   The CRS must demonstrate the ability to oversee the chart review life cycle from scheduling access, collecting images, coding chart and updating data software. The CRS must have the ability to code on both and INP and OPD basis. Will participate in monthly Inter-rater reliability discussions to develop and enforce coding P&Ps and define Coding Standards and best practices. Accept assignment from the Manager. Maintain strong interdepartmental relationships. Light travel may be required.      
Job ID
5813
Product Line
FCHP
Job Locations US-NY-Amherst, NY
Posted Date 1 month ago(4/24/2020 4:01 PM)
Fallon Health Weinberg is a partnership between Fallon Health of Massachusetts and Weinberg Campus of Erie County, New York. Fallon Health Weinberg offers a Program of All-Inclusive Care for the Elderly (PACE) and a Managed Long Term Care (MLTC) plan to serve the health needs of dual-eligible residents of the Western New York counties of Erie and Niagara. Fallon Health Weinberg expands the choices that residents of Erie and Niagara Counties have when it comes to high-quality, affordable health care. Founded in 1977, Fallon Health provides health care services designed to meet the unique and changing needs of all they serve. It consistently ranks as one of the nation's highest-rated health plans, according to the National Committee for Quality Assurance (NCQA).* Fallon Health coordinates care with its Senior Care Options/Special Needs Plan for dual-eligible people who are 65 and older. Fallon Health has operated a PACE program in Massachusetts for more than 20 years and is the largest PACE program in New England and sixth largest nationally.**   About Fallon Health Weinberg-PACE: Fallon Health Weinberg-PACE is a long-term care program for older adults who qualify for a nursing-home level of care, but wish to stay living at home and in their community. We are a Program of All-inclusive Care for the Elderly (PACE), providing complete medical care and support services that helps people to remain living safely at home. All care is coordinated and provided by an interdisciplinary team specializing in geriatric care, working with participants and their caregivers to create an individualized care plan.   As part of the PACE interdisciplinary team, responsible for the coordination and monitoring of care and services to maintain participants in a safe community environment. 
Job ID
5783
Product Line
Fallon Health Weinberg

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