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Fallon Health Associate Medical Director - Utilization Review - Part Time in Worcester, Massachusetts


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:

This position works with both inpatient and outpatient Care Management nurses to monitor appropriate care and services in hospitals, skilled nursing facilities and home care settings to ensure quality, cost-effectiveness and continuity of care. Also works with both inpatient and outpatient care managers on individual member cases to ensure the effectiveness of care management programs. Participates in physician reviewer and preauthorization meetings to coordinate and assure consistent application of FCHP guideline criteria; also to assure appropriate administration of member benefits as outlined in individual product line Evidence of Coverage Handbooks and the Benefits Manual.


Primary Job Responsibilities:

  • Provide clinical support for prior authorization process

  • On-site, off-site and telephonic inpatient case management rounds

  • Outpatient case management rounds

  • Provider appeals review

  • Member appeals review

  • Pharmacy issues and referral requests

  • Medical director on-call coverage

  • Support the benefits and technology review process

  • Provide support for UM administrative infrastructure

  • Participate in the HP’s strategic planning process and establish yearly financial goals and monitor progress toward such goals as part of the strategic plan.

  • Develop annual goals and objectives and submit to an annual evaluation by the President.


Education, Licenses, certification and experience requirements:

  • Unrestricted license to practice medicine in MA (or licensable).

  • Board certified in medical or surgical specialty.

Fallon Health Vaccination Requirements:

To protect the health and safety of our workforce, members and communities we serve, Fallon Health now requires all employees to disclose COVID-19 vaccination status. As of 2/1/2022, all roles not designated as “Remote” require full COVID-19 vaccination and Fallon Health will obtain the necessary information from candidates prior to employment to ensure compliance. Failure to meet the vaccination requirement may result in rescission of an employment offer or termination of employment.

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.

Location US-MA-Worcester

Posted Date 6 months ago (4/19/2022 10:18 AM)

Job ID 6818

# Positions 1

Category Medical Management