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Fallon Health Manager, Enrollment & Billing Quality & Distribution Services 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 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 .

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:

Under the direction of the Director of Enrollment and Billing Operations, the E&B Quality and Distribution Services Manager leads all Operational tasks related to quality assurance of data entered/maintained by the commercial and regulatory business. This includes but may not be limited to all enrollment and billing transactions, enrollment application batching, PRA entry, PCP assignments and member notifications, reconciliations for regulatory agencies and employer group business, meeting all requirements of State and Federal regulations to meet compliance standards. The E&B Quality and Distribution Services Manager collaborates effectively with co-workers and other departments to ensure quality service to our internal and external customers, and validates processes are being completed timely and in accordance with our policies and procedures as they pertain to internal audit requirements. Through quality control and departmental audits to help identify gaps in our procedures as they relate to our internal audit practices and escalate concerns to the Director of Enrollment & Billing Operations. They must have the ability to analyze various situations and be able to make independent decisions on best practices in the interest of the members and the health plan to remain within compliance.

The E&B Quality and Distribution Services Manager leads all tasks associated with Distribution Services. This includes but may not be limited to sorting and delivery of incoming mail, preparation of outgoing mail, monitoring inventories. The E&B Quality and Distribution Services Manager will work with other departments in the organization to coordinate pickup/delivery of computer equipment and supplies needed for remote workers.


The E&B Quality and Distribution Services Manager will work to develop new or enhanced processes and integrating them into the current workflow after testing. Continually review workflows to find more efficient ways to perform tasks through changes and automation. Key person for upgrades of all systems utilized by the Enrollment & Billing Operations. This involves extensive testing prior to integration. Design test packets for use with upgrades. This includes the writing of new procedures for updating the existing Training and Procedure manual.

Additionally, the E&B Quality and Distribution Services Manager is accountable for establishing and maintaining productive relationships with internal departments across FH. At times, the Manager may be called upon to represent the department in projects or special assignments. He/she is expected to balance the requirements and perspectives of the operation and the project to produce outcomes that are mutually beneficial and meet the needs of the business.

The E&B Quality and Distribution Services Manager is committed to the development of the knowledge and skills of the Distribution Services and Enrollment & Billing teams. This requires ongoing support and supervision of daily activities and deliverables. He/she is expected to establish performance standards and to provide coaching and performance management to ensure the collective success of the team. It is the role of the manager to inform all stakeholders of the department’s work regarding shared commitments and deliverables. He/she will lead the identification of risks and contingencies as new initiatives are introduced and will plan and communicate accordingly. Working with the Director, the E&B Quality and Distribution Services Manager will prioritize opportunities for process improvement and will ensure the impact to other departments is identified and communicated.

Manage the departments business operations

Implement, manage and refine business processes required to deliver expected business results.

  • Ensure all CMS and State requirements are met/exceeded

  • Manage the implementation of process improvement, as appropriate.

  • Implement staffing plans to ensure anticipated operational requirements are met. Monitor workload fluctuations and adjust staff assignments accordingly.

  • Ensure team has appropriate resources and highlights areas of need to Director for resolution.

  • Ensure the timely and accurate exchange of information/data with relevant stakeholders of the operation.

  • Monitor the work environment and the business operation. Address concerns that may affect the morale and/or operational effectiveness of the group.

  • Responsible for ensuring timely and accurate eligibility and premium audit procedures are in place and being performed through direct performance. Ensures that department turnaround times and quality standards are met.

  • Works proactively to ensure the enrollment and billing records are kept current and accurately. Ensures goals and turnaround standards are being met or exceeded based on corporate and departmental metrics.

  • Review’s data integrity reports to ensure tasks are done timely and accurately.

  • Ensuring contract and billing objectives are being met

  • Prepare documentation for internal and external auditors as required

  • Ensure Model Audit Rule (MAR) internal controls and compliance is maintained

  • Maintain professional etiquette and positively represents Fallon Health.

  • Enter and maintain data in the E&B tracker in a timely and accurate fashion to be utilized for metric reporting purposes

  • Assists with core system upgrade testing

  • Manage equipment transfers between IT and employeesEnsure incoming/outgoing mail is handled timelyMaintains files and records usually of highly confidential nature. Prepares confidential and special reports as requireMetric Reporting – Creation of reports to be distributed to Management staff Produce daily reports for use by department staff.

  • Ensures that all certified mail is logged and gets to the Post Office on a daily basis for all departments (3:30pm) in addition to a 4:30pm pick up for HMS. Delivers mail to Post Office 1-2 times daily utilizing the FCHP van. Ensures mail is secured and delivered to the Post Office daily. Utilizes safety and confidentiality. Represents Fallon in a positive and professional manner. Has a valid driver’s license.

  • Ensures delivery of all boxes, packages etc. and logs them and gets a signature from recipients. Ensures all boxes and packages are delivered to the correct person or department. Ability to handle a two- wheeler, mail cart and pallet jack.

  • Oversee processing and deliver return mail to the appropriate department for handling

Manage and Develop Staff

  • Define roles and accountabilities for staff, within the group and in the context of the broader process/operation in support of cross-functional efforts.

  • Hire for, develop and recognize the experience and knowledge/skills/abilities required for a successful team.

  • Provide for the orientation and welcome of new staff.

  • Define performance expectations and goals for staff.

  • Train and mentor staff on the application of policy and procedures, use of supporting systems/applications, appropriate soft skills: time management, etc.

  • Monitor work of individual staff for efficiency, effectiveness and quality. Provide ongoing constructive feedback and guidance to staff.

  • Evaluate staff on achievement of goals and deliverables and assessment of competencies. Help staff progress in their careers to the benefit of the department and broader organization. Manage the resolution of performance issues in consultation with Human Resources as appropriate

Provides subject matter expertise to other areas of the company

  • Act as a resource person for team members in all areas of the work.

  • Assist the team in resolving administrative and routine operational issues as they arise. Serve as point of escalation with internal and external customers as necessary to resolve issues.

  • Promote the use of accepted best practices and innovative strategies.

  • Establish and maintain an open communication channel with staff.

  • Monitor effectiveness of communication with other groups (internal and external). Collaborates with Director to implement changes as necessary to ensure an open, productive exchange of information.

  • Represent the department as requested.

  • Ensure operational compliance with all relevant regulatory agencies.

  • Ensure operations meet vendor/customer contractual requirements.

  • Keep abreast of changes in requirements.

  • Work with external vendors with relationship to equipment rentals/maintenance

  • Proactively identify areas of concern or exceptions and promptly notify stakeholders.

Participate in planning and analysis and implementation for new products/projects

  • Participate in cost/benefit analyses of operational changes in support of future business requirements.

  • Work with Operations Support to develop and maintain metrics and measurement to support a consistent, informative, and timely management reporting package.

  • Regularly analyze and report on the productivity and effectiveness of the operations in comparison to established performance metrics. Identify areas of improvement and recommend resolution.



  • Education: Bachelor’s degree in business or comparable business experience.


  • 5+ years managerial experience

  • QNXT, Avenue, Microsoft, CMS, Medicaid/internal databases, Credit Card system, Santander Bank, Alterex, Cathedral, Invoice Cloud, FED/GIC Systems

Physical Requirements of role:

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.Usual office environment with frequent sitting, walking, standing, and occasional climbing, stooping, kneeling, crawling and balancing. Frequent use of eye, hand and finger coordination enabling the use of office machinery. Oral and auditory capacity enabling interpersonal communication as well as communication through automated devices such as the telephone.

Occasional: activity exists less than 1/3 of the time

Frequent: activity exists 1/3 and 2/3 of the time.

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 1 month ago (9/2/2022 3:00 PM)

Job ID 7019

# Positions 1

Category Enrollment & Billing