Care Management Regulatory Manager - Hybrid

Fallon Health; Central Business District (MA); On-site; USD 70,000 - 90,000; Full time

Job summary

Fallon Health seeks a Care Management Regulatory Manager responsible for ensuring compliance with CMS regulations and NCQA standards. The role involves auditing clinical documentation, delivering feedback, and ensuring high-quality member care. Ideal candidates will have 4+ years of auditing experience in healthcare and strong critical thinking skills.

Qualifications

• 4+ years audit experience in a health care setting.
• Experience with NCQA, CMS, and EOHHS regulations.
• Ability to develop audit tools and teams.

Responsibilities

• Conduct audits on clinical documentation for compliance.
• Deliver audit feedback and implement team corrective actions.
• Participate in internal and external audit activities.

Skills

Audit skills

Critical thinking

Customer service

Education

Bachelor’s degree in health care

Tools

Microsoft Office (Excel, Outlook, Word)

Job description

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, 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.

Summary of purpose:

The Care Management (CM) Regulatory Manager is an essential function to Fallon Health’s compliance with CMS regulations, NCQA standards, EOHHS applicable regulatory requirements, and internal policies and procedures. This role ensures adherence to Care Management policies and processes and CMS and EOHHS contract requirements.

The Care Management (CM) Regulatory Manager serves as the expert on regulatory contract requirements, NCQA standards and internal CM department policies for the care management department. Their role is to ensure high quality member care is provided as evidenced in member care plans, call monitoring, CM collaboration with members, caregivers and providers and interdisciplinary care management and coordination to ensure whole-person centric care is delivered to each Fallon Health member.

This role supports the CM department in internal and external audit procedures, including, but not limited to, preparation of data universes and case preparation, active narrating and oversight of CMS, spotlight, IPRO, NCQA and other applicable regulatory and internal-compliance audits.

Responsibilities

Care Management (CM) Regulatory Manager Responsibilities Includes:

• Audits clinical documentation, completing objective audit tools ensuring team member compliance with regulatory and accreditation requirements

• Audits documentation ensuring documentation meets quality standards and interventions and actions are effective to meet member needs

• Delivers audit result feedback to clinical staff and their leader and works in conjunction with the leader to implement leader developed team member corrective action plans when warranted

• Audits clinical documentation and ensures compliance to established competency standards and regulatory needs, working in conjunction with staff and Department Leaders to improve team member performance

• Review case and call documentation for thoroughness and accuracy and recommend and implement training improvement changes

• Conducts audits on a regular basis according to the policies and procedures as assigned by Leader.Perform root 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 Team Leadership 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

• Supports Care Management with all internal and external audit activity

• Commands overall understanding of Department goals and processes, including introductory database reporting management

• 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

• Maintains up to date knowledge of Fallon Health products and benefits, product specific Evidence of Coverage details, and department policies and processes

• Other duties as assigned by Leader

Qualifications

Education:

Bachelor’s degree in health care or equivalent experience in managed care required

License/Certifications:

License: NACertification: NAOther: Satisfactory Criminal Offender Record Information (CORI) results

Experince:

- 4+ years audit experience in a health care setting required- Proven competencies in entry level care coordination and/or care management role responsibilities required- Experience with NCQA, CMS, EOHHS and/or other required regulatory requirements and audit procedures required - Experience with developing audit tools, auditing team member performance, and working with staff to improve their performance required- 3+ years experience in compliance, clinical quality, care coordination/case management in a health care setting preferred- Experience in a managed care/payor organization with regualtory contracts preferred- Experience in auditing and/or training clinical and non-clinical staff, and demonstrated knowledge of case management preferred

Demonstrated proficiency including but not limited to:

• Ability to develop a system and process to objectively measure care management competencies and to hold team members accountable• Ability to identify gaps in staff’s knowledge base and to support training team to identify needs for additional training and potential remediation• Support leadership with identifying gaps in competency and compliance to strategize improvement methodologies • Advanced skills in software systems including but not limited to Microsoft Office Products – Excel, Outlook, and Word • Manipulation of Excel spreadsheets to manage work and exposure and familiarity with pivot tables desirable• Exceptional customer service skills and willingness to assist ensuring timely resolution • Working with an interdisciplinary care team as a partner demonstrating respect and value for all roles and is a positive contributor within job role scope and duties• Knowledgeable about medical record documentation • Critical thinking skills for independent problem solving

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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