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Fallon Health Medicare Compliance & Regulatory Affairs Associate 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.

Brief Summary of Positions:

The Medicare Compliance & Regulatory Affairs Associate acts as a regulatory resource to clarify, monitor, and research regulatory requirements, provides proactive compliance monitoring and assessments with regards to key initiatives and increasing compliance requirements, collaborates with business areas and vendors to manage corrective action processes when needed, and supports CMS audits. This includes changes that impact the structure and operation of Medicare Advantage, PACE and other Medicare products as well as Medicare initial and expansion applications, RFIs, RFAs, and compliance versight. Develops legal arguments for Medicare Programs as needed. A component of the position is dedicated to compliance management of Medicare required reporting in accordance to the state and federal requirements. Additionally, this position includes Fallon Policy and Procedure Librarian responsibilities that include sending annual review policy and procedure reminders to business areas, providing education on the development of and uploading of final policies and procedures.


  • Conduct research regarding regulatory and benefit questions to support business requirements including product development, procedural issues and changes for Medicare Advantage, PACE and other Medicare products.

  • Assist operational areas, as needed, with the development, updates and/or revisions relevant policies and procedures based on updates to interpretation or regulatory changes from state or federal regulators.

  • May include research and analyses of matters related to existing and new regulatory requirements as well as assisting with Medicaid regualtions as needed.

  • Assume a major role in CMS and State leading work groups and developing work plans that focus on readiness and compliance with CMS and Stateregulations, manuals and review guides including such areas as:

  • Fraud, waste and abuse oversight requirements.

  • Reviewing and retaining company contracts and other documents pertinent to the Medicare product(s)

  • Coordinating with business areas to gather information needed for regulatory reviews, validations and audits.

  • Manages and submits the required Medicare (i.e. Part C & D) reporting as delegated by management. This includes working with multiple Fallon departments and vendors to ensure the submission of data to CMS is in compliance with reporting requirements, and assists with the yealry Part C & D Data Validation.

  • Responisble for the oversight of required Medicare Advantage and PACE encounter data reporting requirements and timeline in collaboration with otherFallon departments.

  • Manage the oversight and d istribution of legislation as it impacts Medicare Advantage, PACE and other Medicare products.

  • Provide support to Medicare Advantage, PACE and other Medicare products application submission process and other submissions as needed.

  • Develop and and prepare arguments and explanations in response to proposed regulatory changes and inquiries for internal meetings as submission to CMS.

  • Seek advice from legal counsel as needed.

  • Manage the compliance oversight of Fallon’s First Tier, Downstream and Related Parties (FDRs), including the annual questionnaire distribution, review and, as needed, follow up required with FDRs. May also include acting as the Chair to Fallon’s Government Programs Vendor Oversight Committee which includes owning the content of the Compliance Program Guide for FDRs and Business Partners and Health Care Providers Code of Conduct documents and the Vendor Compliance section of the Fallon Health website.

  • Develop, update and/or revise relevant policies and procedures within Medicare Programs based on updates to interpretation or regulatory changes from state or federal regulators.

  • Act as a Librarian for certain business areas throughout the organization. This includes sending reminders of the annual reviews as well as providing education on what policies and procedures are and what they are to contain, and uploading of final policies and procedures.

  • Engages in various organizational committees and/or work groups to monitor or prepare for CMS audits, coordinates corrective action plan as well as disseminate federal program compliance information as necessary.

  • Provide support during audits, to Medicare Advantage and PACE product(s) application submission process and other submissions, and other Medicare Programs special projects and assignments as needed.




Bachelor’s degree required. Advanced degree in law strongly preferred for this position *     *


5 years managed care or relevant industry experience

Location US-MA-Worcester

Posted Date 3 weeks ago (5/11/2020 10:40 AM)

Job ID 5969

# Positions 1

Category Medicare Medicaid Programs