Overview:
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, we deliver equitable, high-quality coordinated care and are continually rated among the nation’s top health plans for member experience, service, and clinical quality.
Fallon Health’s Summit ElderCare® is a Program of All-Inclusive Care for the Elderly–PACE for short. PACE, an alternative to nursing home care, is a program that helps people 55 and older continue living safely at home. At Fallon Health, 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— in the region.
Brief summary of purpose:
The Manager works closely with their counterpart to assist the Senior Director, PACE Operations to manage the program level operational and regulatory functions related to Fallon Health’s PACE programs. Responsible for compiling reports and analyzing data and making program level recommendations. The Manager supports the Senior Director, PACE Operations to manage program level operational and regulatory functions in support of the program’s quality, strategic and financial goals. Responsible for supporting PACE sites related to the development and implementation of processes and workflows, network development, contract management, claims, billing, and authorization assistance. This position requires regular travel to all Summit ElderCare sites and occasional travel to FHW PACE to provide support/guidance on various operational topics. Travel = 10% of the time
Responsibilities:
Primary Job Responsibilities
Is responsible for ensuring accurate payment of the PACE medical claims:
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Responsible for managing the SE QNXT claim inventory
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Responsible for following up with Supervisors of Support Staff to ensure that the pended claims are being processed timely
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Responsible for reviewing authorization issues that result in incorrect payment and working with site staff to resolve issues in a timely manner
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Responsible for ensuring that necessary training is conducted so that office staff is able to complete daily billing and claims responsibilities
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Works with FH UM, Provider Relations, and Claims departments to troubleshoot authorizations and claims issues
Is responsible for overseeing the PACE Service Coordination Unit:
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Responsible for managing and supervising the SE Service Coordinators
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Responsible for ensuring SE Service Coordinators are working quickly to secure needed home care services for PACE participants
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Responsible for conducting random call audits on a regular basis to ensure quality customer service and appropriateness of call content
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Responsible for ensuring that necessary onboarding, training, ongoing regular supervision/touchpoints and, if needed, performance management, is carried out with all Service Coordinators
- Has regular communication with external home care vendors and Service Coordination Unit to ensure good business partnerships
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Works with site teams to ensure Service Coordination unit receives the needed information in order to secure appropriate in-home services for PACE participants
Committees & Workgroups:
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Attends meetings and acts as Operations subject matter expert as assigned
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For assigned meetings, prepares agenda in collaboration with Senior Director, PACE Operations
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Responsible for meeting follow ups
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Records meetings, documents key points and necessary follow up, sends out link to meeting minutes in a timely manner to all attendees
PACE Member Satisfaction:
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Reviews monthly SE satisfaction surveys
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Responsible for following up with the sites to resolve participant and caregiver issues/concerns
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Attends the monthly FH Service Advisory Committee meeting as PACE representative and reports on satisfaction survey scores below 9 as well as other Service Quality related topics
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Attends SE Service Quality Meeting quarterly and works with SE leadership and PACE sites to plan interventions and improvement activities for increasing Participant satisfaction scores, reports back to FH Service Advisory Committee
Conduct systemic monitoring of pended claims inventory:
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Communicates with relevant PACE sites and monitors for resolution
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Strives to improve processes while leveraging assistance and resources from other Fallon Health departments
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Support ongoing adherence to Summit ElderCare billing policies and procedures
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Ongoing interaction and coordination with FH Enrollment and Billing Operations, Medicaid Coordination and SE Clinical staff
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Responsible for communication and implementation of changes at the PACE site level including FHW PACE as applicable
Management of SE Policies & Procedures:
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Responsible for annual reviews, updates and maintenance to Summit ElderCare policy and procedures, as assigned.
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Responsible for updating PACE policies and Process Documents on an annual basis, uploading to the SharePoint site and providing training as needed for new procedures and workflows, as assigned
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Research and update policies and procedures including workflows and communication
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Makes needed edits to policies and process documents and presents to the Senior Director, PACE Operations, SE Senior Director of Nursing & Quality, and SE VP/Medical Director, respectively, according to category (i.e., Operations & Administration, Quality & Clinical).
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Works closely with assigned “Librarian” to ensure updated policies and process documents are posted in a timely manner to the SharePoint site
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Develops policies/procedures and workflows for key operational processes and manages the communication/implementation.
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Ensures that established annual review deadlines are met
Contracted Vendor Oversight:
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Ensures that completed attestation is on file for each direct care vendor not subject to regular vendor audits
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Ensures all prospective vendors/providers understand expectations and PACE requirements prior to proceeding through the contract negotiations process
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Receives and manages all Contract Requests in a timely manner
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Participates in vendor/provider contract negotiation meetings as assigned
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Communicates all newly effective contracts to the PACE sites and PACE leadership team on a monthly basis
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Provides comprehensive onboarding to all newly contracted home care and transportation partners to ensure adherence to requirements
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Conducts vendor audits (either in person or virtually via data exchange), as required, and vendor oversight as required by Vendor Oversight Policy
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Provides all necessary materials to vendors prior to their scheduled audit
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Completes all necessary reporting and follow up documentation after each audit
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Collaborates with Compliance to ensure audit processes remain current and aligned with CMS regulations
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Acts as back up to Senior Director, PACE Operations as SE representative on Government Programs Vendor Oversight Committee
Other Operations Responsibilities:
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Acts as a resource to and supports PACE Senior Leadership Team in various program-wide projects and initiatives as needed and assigned
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Works with Application Support Specialists and others in FH’s ancillary departments (IT, Medical Economics, etc.) to build reports and collect data as necessary from the EMR and QNXT
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Supports the PACE Home Care Manager and Service Coordination Unit as needed
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Assists in preparing the organization (both SE and FHW PACE) for all site reviews or audits conducted by CMS, the State or other external regulatory entities
- Provides periodic updates to the PACE leadership team.
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Attends program-level, organizational-level and external meetings and committees representing PACE operations as assigned and reports key updates to Senior Director, PACE Operations
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Serves as a lead on key PACE projects as identified. Responsible for timely and complete execution on all assigned projects from project plan development to implementation. As appropriate, utilizes the PDSA process in all process improvement activities across FH’s PACE line of business
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Compiles data for assigned CMS data universes
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Compiles data for PACE monthly regulatory monitoring program and dashboard
SE Liaison for Network Development & Management and Purchasing Department
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Works closely with the Senior Director, PACE Operations to ensure network adequacy and timely procurement of needed contracts in all areas and States where Fallon Health offers PACE
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Maintains spreadsheet of all requests made to NDM and/or Purchasing departments for tracking purposes
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Works closely with the Site Directors to ensure all contract request forms are addressed timely
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Ensures list of PACE contracted Providers is updated and distributed to all SE sites and PACE leadership team
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Provides monthly updates to SE sites and PACE leadership team on upcoming contract effective dates
SE Premium Payment Discrepancy Report
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Collaborates with the Government Programs Eligibility Manager to review the SE discrepancy report to ensure the Government Programs Eligibility Specialists (GPES) are working each assigned case to reinstate participant Mass Health coverage
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Reviews weekly 834 reports to ensure all dual eligible members are captured
- Ensures that SE Payment policies and other related policies are adhered to regarding participant non-payment of premiums
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Notifies the site of any participant outstanding balances and collaborates with the site to resolve payment discrepancies
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Meets regularly with FH Enrollment & Billing Operations to review other non-eligibility payment discrepancies (i.e., PPA discrepancies and spend downs) and works with PACE site staff to obtain all necessary verifications to ensure coverage retention and to avoid involuntary disenrollment from the plan
Qualifications:
Education
High school diploma required. Associate’s or bachelor’s degree in related field preferred
Experience
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3-5 years’ experience in health care or insurance setting preferred
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At least 2 years in a supervisory capacity
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Strong background in customer service and advanced computer skills required
- Proficiency in Microsoft Excel required; experience with NextGen, SQL, QNXT, CRM and Verint highly desirable
- Excellent written and verbal communication skills
- Ability to establish effective productive relationships with peers and leaders
- Ability to work independently and exercise sound judgment
- Ability to establish effective records-keeping systems and prepare clear and concise reports
- Comfortable delivering constructive feedback to peers and indirect reports on performance and productivity
- Comfortable interacting with individuals at all levels of FH.
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Comfortable interacting with and onboarding newly contracted external partners
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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