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Fallon Health Director of Quality in Worcester, Massachusetts


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.

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 Director oversees, plans, coordinates and evaluates a comprehensive quality program toensure the quality and safety of clinical care and quality of service provided to all members across all product lines. This includes working very closely with the Director of Quality Data Systems on the collection, management and analysis of quality data and the preparation of quality reports to various external agencies.

This position is responsible for oversight of the medical record component of the the annual HEDIS® submission to NCQA, Medicare and Medicaid clinical quality programs and maintaining NCQA Health Plan accreditation. They direct all areas related to quality and compliance with NCQA, Center for Medicare and Medicaid (CMS), and federal and state regulations. Provides oversight on behalf of the health plan to all vendors that are delegated with managed care functions to ensure that all downstream entities comply with NCQA and other regulatory requirements related to quality.


Job Responsibilities:

  • Provides leadership, trains, develops and evaluates direct reports.Hire, on board, and develop a successful team.

  • Directs and provides leadership for compliance with National Committee for Quality Assurance (NCQA) standards

  • Collaborates with other leaders in developing, monitoring, and evaluating Healthcare Effectiveness Data Information Set (HEDIS) improvement action plans, medical record review, and over read processes.

  • Responsible for all quality activities within the health plan, including the infrastructure, committees, reporting, and outcomes measurements in order to comply with the national accreditation with NCQA (National Committee for Quality Assurance) and federal and state regulatory requirements.

  • Provides oversight to the government programs, Medicare and Medicaid quality programs and ensures that Fallon Health meets the requirements for the Center of Medicare and Medicaid and the Massachusetts Division of Medical Assistance contractual requirements.

  • Develops and implements policies and procedures that ensure compliance with legal and other external regulations/requirements and supports the continuous improvement of the quality of service provided by the department.

  • Oversees and evaluates the Annual Quality Work Plan.

  • Increases standardized quality scores used by NCQA particularly HEDIS by implementing specific health activities that promote the rates.

  • Accountable to audit requests from MassHealth for the External Quality review of Performance measures as well as CMS.

  • Leads the population based programs to improve the health and wellness of FCHP members by implementing interventions that will motivate members to participate in preventive screenings.

  • Collaborates with physicians within the network to remind them of members who have not received appropriate screenings and treatments according to nationally recognized guidelines.

  • Establishes a budget for Quality Services that provides adequate resources, materials, and personnel to serve the health plan’s quality infrastructure and continuous monitoring of the quality program as well as tracking expenses and documenting rationale for variances.



Master’s Degree in health administration, public health, nursing or related health.


Nursing or other related discipline preferred, CPHQ certification preferred.

*Experience:  *

  • Minimum of 3-5 years experience in a leadership role within a health care setting directing quality management programs with an emphasis on measurable outcomes based on application of continuous improvement principles.

  • Must demonstrate a proven track record in achieving measurable health services improvements and knowledgeable about health plan accreditation requirements, HEDIS® and regulatory requirements. * *

  • Must be proficient in the use of Microsoft Office.

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 2 weeks ago (5/11/2022 10:27 AM)

Job ID 6853

# Positions 1

Category Quality