Fallon Health Program Manager Looking for a new Career Fallon Health Insurance! in Worcester, Massachusetts

Overview

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.

Job Summary

This position is accountable for supporting the delivery system to improve member’s health outcomes, oversight of assigned delegated activities and participation in the company’s STARS and GIC quality improvement initiatives by: 1) Assisting providers to deliver improved patient care. 2) Educatingtheprovider community on impact of CAHPS, HOS and HEDIS on member outcomes and STARs performance. 3) Assessing provider office practices for opportunities that positively impact member experience and impact HEDIS, CAHPS and HOS ratings. This position will be required to communicate and collaborate with value based and non-valued based partners as well as other stakeholders to effectively manage the delivery of strategies, plans and improvements to HEDIS, Medicare Stars, GIC Quality Improvement Initiatives, Qualified Health Plans/Quality Rating Systems and other clinical quality measurements. Knowledge and utilization of health analytic tools is required to identify opportunities to improve satisfaction and quality.

Responsibilities

Primary Job Responsibilities

  • Serves as the primary point of contact for targeted populations within Fallon Health.

  • Utilizes health analytic tools to identify trends and opportunities (within a population in a specific geographic area)

  • Collaborates on the development of population health and quality improvement initiatives

  • Support value based arrangements and collaborative care providers with management of their members.

  • Assist members to obtain preventive screenings and review for adherence with prescribed medications

  • Participate in Fallon Health’s annual HEDIS collection including but not limited to medical chart review, abstracting clinical data from EMRs, and collection of various supplemental data points.

  • Inform and educate the care team on care gaps, activities, issues or concerns about the population and from the value based programs.

  • Collaborate with Member, Member’s Personal Representative, Member’s Physicians, Plan Medical Directors, Managers, as well as other functional area to assist the member to meet their health care goals, reduce care gaps, improve health outcomes, and reduce the total cost of care.

Perform other duties as assigned.

Qualifications

Qualifications Requirements

  • Current Massachusetts RN licensure

  • Bachelors’ degree in related field (i.e. Nursing, Healthcare, Business) or equivalent experience

  • 2 years’ experience in health insurance or managed care

  • Ability to interact with medical staff, peers, and internal company staff at all levels

  • Basic to intermediate experience in MS Word, Excel, tablet and/or smartphone

  • Travel as needed for on-site member/provider meetings, events or manager requests.

  • Must have valid driver's license and reliable transportation

  • Flexibility

Must be able to work in a multi-functional team setting

Preferred Criteria

  • Experience and or knowledge of HEDIS/CMS/Quality preferred

  • Project management skills

  • Experience with healthcare quality improvement strategies

PM16

Job ID 5354

# Positions 1

Category Nursing