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Fallon Health Senior Compliance Auditor - Health Care - Member Appeals and Grievances - Flex Remote!! 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 fallonhealth.org.

Brief summary of purpose:

The Fallon Health Senior Compliance Auditor is an essential function to Fallon Health’s compliance with CMS regulations, NCQA standards, other

applicable regulatory requirements and member expectations. The Senior Compliance Auditor ensures adherence to the Fallon Health Appeals and

Grievance process as outlined in the Plan Member Handbook/Evidence of Coverage, departmental policies and procedures, and regulatory standards.

The Senior Compliance Auditor serves to ensure that pertinent data regarding member grievances and appeals is captured and entered into the

appropriate IT application, in compliance with the health plan, governmental and accrediting agency requirements.


Primary Job Responsibilities:

· Ensures adherence to Fallon Health Standard and Expedited Appeals and Grievances processes as outlined in Member Handbook/Evidence of Coverage, and in compliance with applicable NCQA standards, CMS, MassHealth and other state or federal regulatory requirements.

· Leads and represents Member Appeals and Grievances-related external CMS audits, NCQA Standards, state audit and/or internal audit.

· Facilitates and completes internal dashboards and universes for accuracy and timeliness.

· Conduct audits on a regular basis according to the policies and procedures as assigned by the Director. Perform root cause analysis to ensure accuracy of departmental processes and identify, when needed, process improvement opportunities. Produce any necessary Corrective Action Plans, Mitigation strategies and associated impact analysis.

· Through quality control and departmental audits, is responsible for identifying gaps in our procedures as they relate to our internal audit practices, and escalates concerns to management. 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.

· Participates in various meetings as a department representative; acts as a representative on various company wide committees. Dessimates policies and procedure information to staff to ensure successful functioning of the Department. Research and resolve system-wide issues, deficiencies, problems and formulate quality improvement measures.

· Meet regularly with Department Director and management team to identify and discuss department and/or identified system issues directly effecting member and staff satisfaction to recommend plans for improvement measures and in developing and implementing specific work plans for improvements in department work processes.

· Propose and participate in training based upon audit results and trending. Ensures operating manuals and procedural documents stay current when regulations change.

· Performs other duties as they are assigned to meet department performance goals and to respond to changing priorities including administrative related tasks.


Education, Licenses, certification and experience requirements:

Education: Bachelor’s Degree preferred

Experience: Five plus years’ experience in managed health care with appeal knowledge, and experience in internal and external regulatory audit


Member Appeals and Grievances Department preferred. Experience as a Member Appeals and Grievances Coordinator preferred.

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 3 months ago (4/5/2022 11:15 AM)

Job ID 6800

# Positions 1

Category Quality