ACO Regulatory Manager - Fallon Health

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: 

This position is responsible for ensuring Fallon Health’s (FH) accreditation of and compliance with regulatory and compliance requirements for the clinical teams serving Medicaid ACO and Community Care programs. This position serves as the project manager to organize and manage projects related to regulatory, compliance, or accreditation requirements including obtaining and presenting appropriate data. Ensures that any ACO Subcontractor is compliant with all federal and state agency regulatory standards.

Primary Job Responsibilities: 

• This position is responsible for ensuring Fallon Health’s (FH) accreditation of and compliance with regulatory and compliance requirements for the clinical teams serving Medicaid ACO and Community Care programs.
• Learns details in the State ACO Contract keeping abreast of changes and updates and is a resource to the Team and others on the contract needs.
  • Proactively monitors NCQA, Medicare, MassHealth, Division of Insurance and Department of Mental Health to identify any changes in regulations, anticipate the effects these may have on the Programs, and help create strategies to prevent negative impact and promote change.
  • Responsible for ensuring the plan is compliant with all federal and state agencies (including MA Executive Office Health & Human Services), regulatory standards and federal and state contracts regarding ACO clinical services and programs offered by the health plan.
  • Manages the ACO Clinical Team policies and processes, ensuring compliance with the State Contract and working with leaders and subject matter experts to create and updates documents as necessary to ensure policies and processes meet contractual requirements.
  • Leads ACO product line audits, coordinating, organizing, facilitating, and working with ACO Clinical Team Leaders to prepare documents for submission including but not limited to finding the appropriate document, preparing according to auditor protocols and working collaboratively to ensure the Team’s successful outcome.
  • Plans and executes improvement steps to fully align with NCQA, Medicare, MassHealth, Division of Insurance and Department of Mental Health regulations.
• This position serves as the project manager to organize and manage projects related to regulatory, compliance, or accreditation requirements including obtaining and presenting appropriate data.
  • Attends meetings and takes notes, tracks deliverables, and keeps the Team focused on task deliverables and completion dates to ensure success meeting deadlines and required activities.
  • For audits and State requests, research documents required, prepares, edits, redacts, and submits documents.
  • Assists with reporting and data needs helping the ACO Clinical Leaders and Partners with data requests and reports.
  • Works with ACO Clinical Leaders and partners associated with data reporting to respond to data and reporting requests which support the Program and the partner relationships. 
• Partners with Compliance area to ensure the integrity and success of compliance programs.
• Represents ACO clinical team perspective in State Bulletins Workgroup. Responsible for ACO clinical team action steps and communicates necessary changes to clinical team.
• Understands the ACO Models of Care and acts as a support and resource for others on the Model.
• Ensures that any ACO Subcontractor is compliant with all federal and state agency regulatory standards.
• Supports department colleagues, covering and assuming changes in assignment as assigned by Director/designee
• Assists with orientation and training scheduling for new ACO team staff members.
• Develops ACO product specific training modules working in conjunction with other subject matter experts and trains on the product as required
• May mentor and train staff on processes associated with job function and role.
• Participates in industry trade workgroups and webinars, i.e. MAHP, ACHP, ACA as needed.

Education:

Bachelor’s degree in business, healthcare, or equivalent experience.

Experience: 

• Minimum of 5 years of experience in Accountable Care Organizations.
• Knowledge of federal and state requirements related to health care including, MassHealth Medicaid, and Division of Insurance mandated requirements.
• Experience with NCQA, CMS, and other required regulatory requirements and experience writing and developing policies and process documents required.
• Experience presenting member files with Regulatory and Accreditation auditors.
• Experience developing 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.
• Demonstrated proficiency including but not limited to:
• • Ability to develop and write policies, processes, program descriptions, and respond to requests for information from governmental agencies.
  • Ability to understand regulatory and accreditation requests and requirements, and collaborative work with department leaders to implement actions and workflows in a simple, reportable, and actionable way.
  • Exceptional customer service skills and willingness to assist ensuring timely resolution.
  • Critical thinking skills for independent problem solving.
• Demonstrates very strong organizational, communication, and collaboration skills

COVID-19 Vaccination:

With the end of the Global Coronavirus COVID-19 Pandemic, Fallon Health no longer requires all employees to be vaccinated against COVID-19 except for employees who are in jobs that under state and federal laws, regulations and policies are required to be vaccinated and/or they are in Member/participant facing positions.

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.