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Fallon Health Director, MassHealth ACO Clinical Services - Great Role in Growing Product Line! 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


A couple of years ago the Baker-Polito administration set out on a new and innovative initiative deemed MassHealth’s Accountable Care Organization (ACO) program with 18 health care organizations participating as partners across the state of Massachusetts. These organizations are working together to provide better integrated health care for their patients with the goals of improving their health and containing costs. These ACOs are expected to cover over 900,000 MassHealth members and include approximately 4,500 primary care providers.

Fallon Health is an integral part of this this exciting initiative with three key ACO provider partnerships in place and we have a fantastic new opportunity for a Director level leader to join us and oversee the Clinical team . This is a wonderful position for the right leader in this field to come in and make their mark and leverage creativity, collaboration, innovation and strong leadership in taking this program to the next level and helping set a vision and strategy for its current and future success.


  • Is accountable for the direction and management of the MassHealth ACO clinical services area, including the development, implementation, maintenance, and monitoring of all clinical programs required in the Mass Health contract.

  • Collaboratively works with Fallon Health Medical Director for ACOs, Fallon Health ACO Operations Team, ACO Partner Leaders, Community Partners, ACO Leaders, and Clinical Integration Leaders to implement the ACO Model of Care as outlined in the State Contract

  • Develops effective and productive working relationships with ACO partners, representing Fallon Health’s needs and the ACO partner needs

  • Analyzes and strategically leads workflows and process development to demonstrate and implement actions required for ACO Contract compliance

  • Establishes positive and proactive working relationships with the ACO partners for ‘all things’ associated with care management and works with Manager, ACO Operations to ensure TruCare and documentation needs and system reporting works collaboratively between Fallon Health and the ACO Partners

  • Participates, in collaboration with the FH Medical Director for ACOs, in model of care strategy development and ongoing planning and analysis

  • Collaborates with Fallon Health Medical Director to develop, refine, and monitor ACO program metrics

  • Works cross functionally and coordinates the involvement of key FH employees within IT, regulatory, UM, Care Services, NDM, and medical economics to ensure client needs are well integrated with the rest of FH business

  • Maximizes the efficiency of the documentation system to ensure effective reporting of team and partner care management actions collaborating with Clinical Integration Leaders when appropriate

  • Ensures effective, collaborative use of the TruCare system between multiple ACO partners and Fallon Health being firm to ensure clear and effective reporting from the system

  • Develops and oversees the implementation of an effective onboarding process for new ACO members in partnership with Fallon Health Customer Service Staff and Unit staff

  • Manages a multi-location clinical team to ensure timely coordination of quality healthcare and care coordination services for Fallon Health members with varying levels of conditions

  • Provides leadership, supervision, and support for Unit staff fostering integration within ACO Partner care teams

  • Ensures documentation of all workflows and processes conducted by staff working on the ACO product line are complete and updated according to Corporate requirements and/or process changes

  • Ensures team functions are audited according to Corporate, Program, and Department Policies/Processes and works with Leaders to implement corrective actions as warranted

  • Ensures Manager, ACO Operations develops a TruCare User Manual specific for the ACO Partners and trains new partner staff on the System

  • Oversees processes to manage and controls access for ACO Partners to the TruCare system working in conjunction with I.T. to ensure proper documentation is in place for the ACO Users and verifies their need for access according to I.T. protocols

  • Works with the Team Leaders and staff to ensure the Care Management requirements of the ACO State Contract are developed and implemented as required working in partnership with Fallon Health I.T. Team

  • Works with the Team Leadersfocusing efforts to ensure TruCare reporting is effective to meet Program Description, State, NCQA, and other required reporting elements

  • Oversees Team’s performance ensuring effective care coordination services as outlined in the Program Description and mutually agreed upon ACO workflows and processes

  • Ensures team performance goals are met and ensures program staff are trained and compliant with departmental and policy requirements

  • Develops ACO product specific training modules working in conjunction with Team Leaders

  • Supports and educates Team members on various levels of non-complex member care coordination interventions and recommending and supporting team actions to ensure effective member care plan development and implementation for members that are not complex – active participant in Rounds with/without ACO Partner participation

  • Develops and implements quality improvement projects and strategies to support the Program in meeting quality and performance measures including, but not limited to, NCQA, HEDIS, State, External Quality Review projects, etc.

  • Oversees the preparation of member cases files for auditors, regulators, and others as required



  • Strategically responsible to participate in the development of the ACO Models of Care and Program Descriptions for the ACO Product and responsible for ensuring MOC compliance with Regulatory, Contractual, and Accrediting requirements

  • Participates in the ongoing revisions to Models of Care and Program Descriptions for the ACO Product to ensure accuracy with current process at all times remaining compliant with Regulatory, Contractual, and Accrediting requirements taking an active lead to implement corrective actions as required

  • Strategically establishes nursing/care management/social work processes to successfully meet Models of Care and Program Description goals

  • Ensures care management system and documentation platforms are reportable and functioning to effectively meet staff member documentation needs and Program outcomes making recommendations for modifications and enhancements for the entire team

  • Recommends and oversees the development of necessary reports required to implement the models of care and works with Clinical Integration Leaders, TruCare Development, I.T. Teams to ensure timely and accurate reports

  • Establishes processes to ensure successful monthly performance on all product specific key performance indicators and works with Leaders to develop and implement corrective action plans as warranted to correct Program performance

  • Responsible for the annual evaluation of the performance of the Model of Care and Program Evaluation and is an active participant in ensuring stakeholder awareness, at all times recommending and implementing corrective action plans and enhancements

  • Oversees and may participate in the development of content for the ACO Team Trainings in conjunction with Team and ensures staff complete all trainings as required

  • Assigns Leaders to actively manage community vendor relationships such as the ACO Partners/Community Partners or other provider partners including but not limited to medical, long term care community service and support providers, behavioral health, community and other partners involved in member care plans and provision of care and oversees the relationships in partnership with the Medical Director and Director, Relationship Manager

  • Assigns Unit Leaders to actively manage projects, coaching and providing guidance and support for successful completion

  • Works collaboratively with the Medical Directors, Product Line Executive Directors, Operations Leadership and other Fallon Health and ACO Partner staff to implement and improve the services provided by the staff to the Fallon Health population

  • Works collaboratively with the Fallon Health Quality Director and Medical Directors to develop and implement quality improvement projects and processes to support HEDIS, and other quality performance requirements assigning staff to perform functions and overseeing outcomes including but not limited to meeting with auditors and others as required

  • Designs and implements new initiatives to optimize cost and quality for the ACO member population

Program Growth:

  • Works collaboratively with Medical Directors, Product line Executive Directors, Operations Leadership and other Fallon Health staff to expand and grow the membership across approved geographic regions ensuring the ACO Clinical Team structure is adequate to meet member care coordination and oversight needs

  • Works collaboratively with the Medical Directors, Product Line Executive Directors, Operations Leadership and other Fallon Health staff to ensure the implementation, modification and enhancement of workflows and operations to meet changing member benefits and criteria so that ACO Team knowledgeable and prepared to provide member benefit education and facilitation

Team/Program Leadership:

  • Ensures Leaders create, document, train and implement efficient workflows for Team being mindful on impacts across Clinical Integration and ensures overall efficiencies from both the Team and Clinical Integration Unit perspectives

  • Provides clinical leadership in identifying and implementing programs to improve MLR across all ACOs deploying the workforce to assist as defined

  • Develops and ensures coordinated program to support members at time of care transition including but not limited to working with network providers, Utilization Management Staff, and others involved in member care

  • Fosters team member participating in care coordination rounds working in conjunction with Utilization Management Staff and other Fallon Health areas ensuring a collaborative approach to care coordination

  • Provides clinical leadership in identifying and implementing programs to address high risk members/high utilizers and to reduce avoidable ED visits and hospital admissions

  • Oversees the development and team efforts and organized approaches to positively affect outcomes (preventative screenings, member satisfaction, and other measurable outcomes valuable to changing requirements)

  • Oversees the development and leadership of team members in various sites, facilitating consistent communications and implementation of workflow and processes to support and implement the models of care, program descriptions, and member care coordination needs

  • Hires, retains, and maintain key talent to meet business needs working with Leaders to ensure a strong cohesive ACO Clinical Team

  • Coaches direct reports and mentors to facilitate team member skill growth, development, and engagement meeting on a regular basis with direct reports focusing on performance to Program and Corporate established goals

  • Continually works with staff to ensure innovation, creativity, flexibility, and efficiencies are implemented to improve processes and outcomes

  • Works collaboratively with Fallon Health Care Services Leaders to enhance Program and operational efficiencies

  • Develops, updates, and and/or ensures the maintenance of Program Policies and Processes per Fallon Health requirements

  • Develops, updates, and and/or ensures the maintenance of Program job descriptions and role goals ensuring team members are knowledgeable on performance expectations and requirements

  • Completes performance evaluations timely and ensures direct reports complete timely according to Corporate requirements

  • Manages resources to meet deliverables and advocates for additional staffing resources only when necessary to meet requirements working collaboratively with other Clinical Integration Team Leadership staff

  • Fosters transparency and accountability in Program performance, team member actions and outcomes on defined key performance indicators

  • Conducts regular team meetings across entire Program/Offices ensuring consistent messaging and delivery of content

  • Responsible to ensure staff perform according to established processes, time frames, and other required performance measures

  • Develops and implements corrective actions when performance not meeting goals

  • Manages department budget ensuring budget adherence in controllable cost centers

Accelerate Key Partnerships and Enrich the Member Experience:

  • Works collaboratively with community partners and providers including but not limited to ACO Care Management Leaders, ACO physicians, hospitals, home health care agencies, community partners, long term services and support providers, and others involved in member care planning and service delivery

  • Supports product specific member retention efforts, evaluates and recommends actions for improvement and implements such to ensure effective customer service to meet member needs

  • Fosters culture of customized care coordination and case management to meet diverse member population needs


  • Performs any additional duties as assigned by the Vice President of Clinical Integration and the Senior Vice President/Chief Medical Officer


Education :Graduate from an accredited school of nursing or social/behavioral health mandatory. Bachelors (or advanced) degree in a health care related field preferred.

License : Active, unrestricted license as a Registered Nurse in Massachusetts; OR Licensed Mental Health Clinician; OR Licensed Mental Health Family Therapist; OR Licensed Independent Clinical Social Worker; AND reliable transportation

Certification : Certification in Case Management strongly desired


  • Minimum of five years’ clinical experience as a licensed clinician managing/coordinating/facilitating/providing care and leading Care/Case Management teams required

  • Minimum of four years of supervisory or management experience in a health care setting; experience supervising/managing a mix of clinical and non-clinical staff required

  • Experience working within an alternative payment and care delivery system, such as anAccountable Care Organization

  • Previous direct experience in consulting to, managing or leading government programs required

  • Previous direct experience with MassHealth programs required

  • Experience in managed care preferred

  • Experience working in a healthcare setting as a member of an interdisciplinary professional team coordinating care for varied populations who are diagnosed with health conditions or chronic disease, including mental illness or substance use disorders required

  • Experience with building care management programs to address social determinants of health

  • Familiarity with in home services both skilled and non-skilled, outpatient services including medical and behavioral health, knowledge of different levels of care including but not limited to acute, rehab, long term, and experience with Medicaid coverage criteria and requirements

  • Experience developing policies, procedures, and workflows required

  • Experience with performance improvement projects including, but not limited to, establishing criteria for report queries, utilizing objective data to improve processes, and implementation of projects required

  • Experience with state licensure and NCQA accreditation, and regulatory requirements, and quality improvement projects required


Location US-MA-Worcester

Posted Date 3 months ago (7/20/2020 9:38 AM)

Job ID 6027

# Positions 1

Category Medical Management