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Fallon Health Senior Quality Assurance Auditor and Trainer-Member Appeals and Grievances 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.


The Fallon Health Senior Quality Assurance Auditor and Trainor is an essential function to Fallon Health’s compliance with CMS regulations, NCQA standards, other applicable regulatory requirements and member expectations. The Senior QA 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 QA Auditor serves to ensure that pertinent data regarding member grievances and appeals is captured and entered into the appropriate IT application, serves as a liaison between systems personnel and end users, provides systems analysis to ensure the needs of the team are met as well as assist in system implementation or training, in compliance with the health plan, governmental and accrediting agency requirements


Primary Job Responsibilities:

  • Ensure adherence to Fallon Health Standard and Expedited Appeals 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. Participate in any internal compliance or external CMS audit or state audit. Assist in the development of trending issues.

  • Orients new staff, serving as a preceptor and provides mentoring to new employees on an ongoing basis.Identify training opportunities, individual and team coaching needs and reports findings to senior management.

  • Review case and call documentation for thoroughness and accuracy and recommend and implement training improvement changes. Monitor and manage strict adherence to turn-around times to ensure compliant with business requirements.

  • Conducts audits on a regular basis according to the policies and procedures as assigned by the Director. Performroot cause analysis to ensure accuracy of departmental processes and identify, when needed, process improvement opportunities.

  • 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.

  • Identifies service issues and processes that impact member satisfaction and provides input to leadership about the issues.

  • 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.

  • Has proven competencies in entry level coordinator and Coordinator II position.

  • Back-up support to MassHealth Board of Hearings process.

  • Commands overall understanding of Department goals and processes, including introductory database management and case triage process. Understands interdepartmental processes and relationships.

  • Serves as a resource for high level specialized project work, serves as a liaison between systems personnel and end users, provides systems analysis to ensure the needs of the team are met as well as assist in system implementation or training.

  • Special projects as assigned by Department Director.


Education, Licenses, certification and experience requirements:

Education : Bachelor’s Degree or equivalent experience in managed health care required

License: N/A

Certification : N/A

Experience : Subject matter expert in Appeals & Grievances


  • Regulatory and compliance

  • Commitment Through Action

  • Contributes to Team Performance

  • Focus Upon Quality

  • Flexible and Adaptive

Additional Performance Requirements:

  • Excellent written and oral communication skills (including public speaking and presentation skills)

  • Excellent computer skills

  • Excellent organizational and analytical skills

  • Excellent interpersonal skills

  • Excellent problem-solving, conflict resolution and negotiation skills

  • Work with compliance of HMO policy and procedure and regulatory requirements

  • Legal training/background preferred but not required.

  • Ability to protect high degree of confidential/privileged patient and proprietary business information

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 (5/25/2021 4:51 PM)

Job ID 6363

# Positions 1

Category Quality