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Fallon Health Program Manager, Medicaid / ACO Quality - Mix of On-Site & Remote Work Week! in Worcester, Massachusetts


Flexible Work Model with a Nice Mix of On-site and Working Remote!

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.

Summary: With general direction from the Director of Quality Programs, the program manager ensures that the health plan is compliant with all quality related obligations required by the Centers of Medicare and Medicaid, the Massachusetts Division of Medicaid (MassHealth) and Senior Care Options (Navicare). The program manager takes the lead on documentation and reporting to the external entities as required by the specific regulators and keeps abreast of changes in the regulatory environment to promote awareness with other directors and senior leaders of the health plan regarding the impact of those revisions to daily operations and procedures. He/she interacts with other managers within Quality Programs to facilitate the design and implementation of clinical quality improvement activities and HEDIS submissions.


  • Oversees all quality activities related to Medicaid and Medicare enrollees, ensuring compliance with all such activities and maintaining accountability for the execution and performance of all program requirements.

  • Maintains an active role in FCHPs overall quality services structure, specifically supports the Medicare and Medicaid quality programs including Senior Care Options.

  • Actively participate in the quality workgroups and other meetings facilitated by EOHHS or other EOHHS contractors.

  • Serves as a liaison and maintains regular communication with EOHHS quality improvement representatives and responsible for timely responses to all requests for information and/or data relevant to quality activities.

  • Produces and submits to the regulator required annual QM/QI Strategic Work Plan, Work Plan evaluations, Quality Improvement projects, etc that shall include planned clinical and non-clinical initiatives.

  • Serves as the Project Manager of the External Quality Reviews activities for Medicaid and Medicare and coordinates staff responsible for the aspects of the review as well as responses to the external agency.

  • Works with other managers within quality programs to, medical directors and administrators to integrate and consolidate data collection and reports.

  • 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.

  • Participates in the annual HEDIS medical record review for Medicare, Medicaid and SCO


Education: Bachelor’s Degree in business, health administration, public health, nursing or related health preferred * *

License: Nursing preferred *     *

Experience: Minimum of 3-5 years experience in a management role within a health care setting directing quality management or care management programs with an emphasis on measurable outcomes.Knowledge of quality improvement processes, statistical analysis, and outcomes measurements. Strong writing and editing skills. Experience managing projects involving cross-departmental teams. Proficiency in Microsoft Suite products specifically Excel, Word, PowerPoint and Access

  • Experience with data analysis and health research with a quantitative focus.

  • Excellent presentation skills

  • Problem solving and analytical ability

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 4 weeks ago (4/9/2021 5:28 PM)

Job ID 6320

# Positions 1

Category Other