Program Manager, Accreditation & Audit- Growing Healthcare Org-Healthcare accreditation & Audit expe

About us:

Fallon Health is a company that cares. We prioritize our members—always—making sure they get the care they need and deserve. Founded in 1977 in Worcester, Massachusetts, Fallon Health delivers equitable, high-quality, coordinated care and is continually rated among the nation’s top health plans for member experience, service, and clinical quality. We believe our individual differences, life experiences, knowledge, self-expression, and unique capabilities allow us to better serve our members. We embrace and encourage differences in age, race, ethnicity, gender identity and expression, physical and mental ability, sexual orientation, socio-economic status, and other characteristics that make people unique. Today, guided by our mission of improving health and inspiring hope, we strive to be the leading provider of government-sponsored health insurance programs—including Medicare, Medicaid, and PACE (Program of All-Inclusive Care for the Elderly)— in the region. Learn more at fallonhealth.org or follow us on Facebook, Twitter and LinkedIn.

Brief summary of purpose:

With general direction from the Director of Quality, the Program Manager, Accreditation & Audit ensures that the health plan is compliant with the National Committee for Quality Assurance standards, the regulations promulgated by the Centers of Medicare and Medicaid, the Massachusetts Division of Medical Assistance, and the Division of Insurance. This position takes the lead on documentation and reporting to the external entities as required by the specific regulators. Keeps abreast of changes in the regulatory environment to promote awareness with other directors and senior leaders of the health plan the impact of those revisions to daily operations and procedures.

Primary Job Responsibilities

• Manages the process of preparing for accreditation reviews and ensures the health plan’s compliance with all NCQA standards, including corporate policies and procedures that support the requirements.
• Acts as the project manager for accreditation and audit activities
• Ensures that the health plan is compliant with NCQA, CMS, EOHHS. Manages the process of preparing for accreditation reviews and ensures the health plan’s compliance with all NCQA standards, including corporate policies and procedures that support the requirements.
• Collaborates with the directors of corporate-wide functions such as quality improvement, credentialing, member rights, utilization management, including member appeals and grievances to support them in accreditation compliance.
• Implements cross functional teams to meet standard requirements for accreditation review and oversees the team’s progress to ensure that timelines are met.
• Coordinates and oversees onsite or virtual accreditation and audit visits from regulatory bodies for the whole care services division

Education:

Bachelor’s degree in health administration, public health, nursing or related health preferred.

Experience : Minimum of 5- 7 years background in managed care and experience with national accreditation standards, regulatory requirements for Centers for Medicare and Medicaid, and the state of Massachusetts quality mandates. Experience managing NCQA surveys. Knowledge of quality improvement processes, statistical analysis, and outcomes measurements. Strong writing and editing skills. Experience managing projects involving cross-departmental teams. PC knowledge should include Microsoft software and database.

COVID-19 Vaccination:

With the end of the Global Coronavirus COVID-19 Pandemic, Fallon Health no longer requires all employees to be vaccinated against COVID-19 except for employees who are in jobs that under state and federal laws, regulations and policies are required to be vaccinated and/or they are in Member/participant facing positions.

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.

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