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via LinkedIn
posted_at: 2 days agoschedule_type: Contractor
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
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 www.fallonhealth.org .
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.
Responsibilities
• 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 regulations 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 State regulations, 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 yearly Part C & D Data Validation.
• Responsible for the oversight of required Medicare Advantage and PACE encounter data reporting requirements and timeline in collaboration with other Fallon departments.
• Manage the oversight and distribution 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.
Education
Qualifications
Bachelor’s degree required. Advanced degree in law strongly preferred for this position
Experience
5 years managed care or relevant industry experience
#AP23 Show more details...
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 www.fallonhealth.org .
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.
Responsibilities
• 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 regulations 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 State regulations, 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 yearly Part C & D Data Validation.
• Responsible for the oversight of required Medicare Advantage and PACE encounter data reporting requirements and timeline in collaboration with other Fallon departments.
• Manage the oversight and distribution 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.
Education
Qualifications
Bachelor’s degree required. Advanced degree in law strongly preferred for this position
Experience
5 years managed care or relevant industry experience
#AP23 Show more details...
via LinkedIn
posted_at: 3 days agoschedule_type: Full-time
About Fallon Health:
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 delivers equitable, high-quality coordinated care and is continually rated among the nation’s top health plans for member experience, service, and clinical quality. Today, guided by our mission of... improving health and inspiring hope, we strive
About Fallon Health:
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 delivers equitable, high-quality coordinated care and is continually rated among the nation’s top health plans for member experience, service, and clinical quality. 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.
About Summit ElderCare:
Fallon Health operates the largest Program of All-Inclusive Care for the Elderly (PACE) in New England and the fifth largest in the country. Called Summit ElderCare, Fallon’s PACE helps provide older adults and their caregivers with a welcome alternative to nursing home care. Participants in Summit ElderCare have access to comprehensive medical services and social support at a Summit ElderCare site while they keep the independence of living in their own homes and communities.
Brief Summary of Purpose:
Functions as a member of the PACE Interdisciplinary Team and provides social work services and support to participants, families, and other caregivers. Provides direction to bachelors level social workers as assigned by Social Work Manager.
Social Worker, LCSW/LICSW, Competitive Salary, Generous Paid Holidays, Great company with a great mission to keep Seniors in their homes!(Springfield MA)
Opportunity to work with a growth-centered team in a positive work environment!
Education:
Masters degree in Social Work
License:
Valid and unrestricted license to practice social work from the Board of Registration of Social Work of the Commonwealth of Massachusetts.
Valid Driver's License and reliable vehicle required.
Certification:
CPR and Alzheimer’s certification or willingness to be certified.
Experience:
At least two years experience in a Social Work capacity, preferably in a community setting, with a minimum of one year experience working with a frail or elderly population.
Fallon Health Vaccination Requirements:
To protect the health and safety of our workforce, members and communities we serve, Fallon Health now requires all employees to disclose COVID-19 vaccination status. As of 2/1/2022, all roles not designated as “Remote” require full COVID-19 vaccination and Fallon Health will obtain the necessary information from candidates prior to employment to ensure compliance. Failure to meet the vaccination requirement may result in rescission of an employment offer or termination of employment.
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 Show more details...
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 delivers equitable, high-quality coordinated care and is continually rated among the nation’s top health plans for member experience, service, and clinical quality. 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.
About Summit ElderCare:
Fallon Health operates the largest Program of All-Inclusive Care for the Elderly (PACE) in New England and the fifth largest in the country. Called Summit ElderCare, Fallon’s PACE helps provide older adults and their caregivers with a welcome alternative to nursing home care. Participants in Summit ElderCare have access to comprehensive medical services and social support at a Summit ElderCare site while they keep the independence of living in their own homes and communities.
Brief Summary of Purpose:
Functions as a member of the PACE Interdisciplinary Team and provides social work services and support to participants, families, and other caregivers. Provides direction to bachelors level social workers as assigned by Social Work Manager.
Social Worker, LCSW/LICSW, Competitive Salary, Generous Paid Holidays, Great company with a great mission to keep Seniors in their homes!(Springfield MA)
Opportunity to work with a growth-centered team in a positive work environment!
Education:
Masters degree in Social Work
License:
Valid and unrestricted license to practice social work from the Board of Registration of Social Work of the Commonwealth of Massachusetts.
Valid Driver's License and reliable vehicle required.
Certification:
CPR and Alzheimer’s certification or willingness to be certified.
Experience:
At least two years experience in a Social Work capacity, preferably in a community setting, with a minimum of one year experience working with a frail or elderly population.
Fallon Health Vaccination Requirements:
To protect the health and safety of our workforce, members and communities we serve, Fallon Health now requires all employees to disclose COVID-19 vaccination status. As of 2/1/2022, all roles not designated as “Remote” require full COVID-19 vaccination and Fallon Health will obtain the necessary information from candidates prior to employment to ensure compliance. Failure to meet the vaccination requirement may result in rescission of an employment offer or termination of employment.
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 Show more details...
via LinkedIn
posted_at: 2 days agoschedule_type: Full-time
Overview
Why should I consider a Nursing opportunity in a PACE program at Summit...
• No Nights!
• No Holidays!
• 8-5 standard schedule!
• The only on-call is a low-volume weekend rotation spread across all the other Nurses!
• Collaborative and supportive full team approach to our care model!
• Some wonderful relationships established with the member participants you care for!
About Fallon Health
Founded in 1977, Fallon Health is a
Overview
Why should I consider a Nursing opportunity in a PACE program at Summit...
• No Nights!
• No Holidays!
• 8-5 standard schedule!
• The only on-call is a low-volume weekend rotation spread across all the other Nurses!
• Collaborative and supportive full team approach to our care model!
• Some wonderful relationships established with the member participants you care for!
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.
About Summit ElderCare
Fallon Health operates the largest Program of All-Inclusive Care for the Elderly (PACE) in New England and the fifth largest in the country. Called Summit ElderCare, Fallon’s PACE helps provide older adults and their caregivers with a welcome alternative to nursing home care. Participants in Summit ElderCare have access to comprehensive medical services and social support at a Summit ElderCare site while they keep the independence of living in their own homes and communities.
Position Summary
Responsible for the effective management and delivery of direct nursing care to PACE participants in any setting utilizing nursing process and adhering to standards of nursing practice.
Responsibilities
Primary job responsibilities:
• Primary nurse not only has the responsibility for the participant, but the authority to advocate for the best care for the participant unique to their situation.
• Fostering a relationship with the caregiver and participant.
• Primary Nurse will take on a Leadership Role.
• Effectively communicate with the healthcare team.
• Assigns tasks and duties to the healthcare team; ensure the tasks are completed; responsible for their panel.
• Develops an individualized plan of care.
• Accountability for assessments, communicating needs and coordinating the care team.
• Primary nurse develops the plan of care
• Reviews and implements Provider’s orders .
• Conducts nursing assessments according to policy guidelines including physical, psychosocial, behavioral, and MDS-HC as indicated.
• Involves participants and significant other(s) based on needs and abilities.
• Delivers care to participants in any setting, including skilled services, based on individualized needs and according to age-appropriate nursing standards.
• Provides for cultural and diverse needs of participants when providing care.
• Monitors and evaluates therapeutic interventions.
• Delegates and or accepts participants’ care responsibilities to other members of the health care team, when appropriate.
• Identifies emergency situations and initiates appropriate nursing orders/interventions.
• Meets the needs of participants in a timely manner.
• Participates in the interdisciplinary team (IDT) process and collaborates with IDT members to meet the needs of participants.
• Consistently documents all aspects of participant care, including significant changes in health status, monthly nurses’ notes and health care teaching in the medical record.
• Participates in training and orientation of new nursing staff as assigned.
• Assists in the delivery of other nursing services as assigned.
• Participates in the nursing “on-call” rotation as assigned.
• Initiates and completes falls, infection, grievance and incident reports
• Participates in CMS calls when deemed necessary.
• Active participant in the site specific committees.
• Participates in the post IDT huddle and any other additional meetings
• Any additional tasks deemed necessary by the Clinical Nurse Manager and or Site Director.
• Assumes the role of the home care nurse, floor or triage nurse per the direction of the Clinical Nurse Manager or Site Director as appropriate.
• Performs all duties in accordance with FCHP and Summit ElderCare policies and procedures.
• Functions independently to administer medications and treatments as ordered by the provider. Functions independently in the primary nurse role. Independent in performing a nursing assessment and executing the plan of care in all settings the participant maybe in.
• Medication administration
• Performing bladder scans, EKG, Point of Care, and glucometer testing
Qualifications
Education, Licenses, certification and experience requirements:
Education: Graduate of an accredited school of nursing
License: Current license as an RN in the state of Massachusetts
Certification: CPR and Alzheimer’s certification, or willingness to be certified within 60 days of hire, is essential.
Experience: At least two years of recent experience in the direct care of adults or chronically disabled persons with at least one year caring for a frail or elderly population.Ambulatory care or home care experience helpful.
Other: Reliable Transportation Required
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.
PM16 Show more details...
Why should I consider a Nursing opportunity in a PACE program at Summit...
• No Nights!
• No Holidays!
• 8-5 standard schedule!
• The only on-call is a low-volume weekend rotation spread across all the other Nurses!
• Collaborative and supportive full team approach to our care model!
• Some wonderful relationships established with the member participants you care for!
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.
About Summit ElderCare
Fallon Health operates the largest Program of All-Inclusive Care for the Elderly (PACE) in New England and the fifth largest in the country. Called Summit ElderCare, Fallon’s PACE helps provide older adults and their caregivers with a welcome alternative to nursing home care. Participants in Summit ElderCare have access to comprehensive medical services and social support at a Summit ElderCare site while they keep the independence of living in their own homes and communities.
Position Summary
Responsible for the effective management and delivery of direct nursing care to PACE participants in any setting utilizing nursing process and adhering to standards of nursing practice.
Responsibilities
Primary job responsibilities:
• Primary nurse not only has the responsibility for the participant, but the authority to advocate for the best care for the participant unique to their situation.
• Fostering a relationship with the caregiver and participant.
• Primary Nurse will take on a Leadership Role.
• Effectively communicate with the healthcare team.
• Assigns tasks and duties to the healthcare team; ensure the tasks are completed; responsible for their panel.
• Develops an individualized plan of care.
• Accountability for assessments, communicating needs and coordinating the care team.
• Primary nurse develops the plan of care
• Reviews and implements Provider’s orders .
• Conducts nursing assessments according to policy guidelines including physical, psychosocial, behavioral, and MDS-HC as indicated.
• Involves participants and significant other(s) based on needs and abilities.
• Delivers care to participants in any setting, including skilled services, based on individualized needs and according to age-appropriate nursing standards.
• Provides for cultural and diverse needs of participants when providing care.
• Monitors and evaluates therapeutic interventions.
• Delegates and or accepts participants’ care responsibilities to other members of the health care team, when appropriate.
• Identifies emergency situations and initiates appropriate nursing orders/interventions.
• Meets the needs of participants in a timely manner.
• Participates in the interdisciplinary team (IDT) process and collaborates with IDT members to meet the needs of participants.
• Consistently documents all aspects of participant care, including significant changes in health status, monthly nurses’ notes and health care teaching in the medical record.
• Participates in training and orientation of new nursing staff as assigned.
• Assists in the delivery of other nursing services as assigned.
• Participates in the nursing “on-call” rotation as assigned.
• Initiates and completes falls, infection, grievance and incident reports
• Participates in CMS calls when deemed necessary.
• Active participant in the site specific committees.
• Participates in the post IDT huddle and any other additional meetings
• Any additional tasks deemed necessary by the Clinical Nurse Manager and or Site Director.
• Assumes the role of the home care nurse, floor or triage nurse per the direction of the Clinical Nurse Manager or Site Director as appropriate.
• Performs all duties in accordance with FCHP and Summit ElderCare policies and procedures.
• Functions independently to administer medications and treatments as ordered by the provider. Functions independently in the primary nurse role. Independent in performing a nursing assessment and executing the plan of care in all settings the participant maybe in.
• Medication administration
• Performing bladder scans, EKG, Point of Care, and glucometer testing
Qualifications
Education, Licenses, certification and experience requirements:
Education: Graduate of an accredited school of nursing
License: Current license as an RN in the state of Massachusetts
Certification: CPR and Alzheimer’s certification, or willingness to be certified within 60 days of hire, is essential.
Experience: At least two years of recent experience in the direct care of adults or chronically disabled persons with at least one year caring for a frail or elderly population.Ambulatory care or home care experience helpful.
Other: Reliable Transportation Required
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.
PM16 Show more details...
via LinkedIn
schedule_type: Full-time
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,
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.
Brief Summary Of Purpose
The Medicare Compliance Analyst & Support Specialist position is an essential role within Fallon Health’s Medicare compliance program and includes activities such as the collection and review of data universes for accuracy to protocols, data analysis to identify risks and trends, developing data visualization and dashboards to portray information to Fallon Health Leadership up to the Audit & Compliance Committee of the Board. This position assists with the monitoring of Medicare compliance-related functions as well as audits from the Centers for Medicare & Medicaid Services (CMS). This position is responsible for completing all departmental reporting and project related tasks accurately and within all required timeframes, maintaining a working knowledge of CMS regulations related to audits and reporting, updating policies and processes as needed, and coordinating CMS audits with collaboration from other Medicare Compliance team members. The position requires excellent organizational skills, an understanding of the importance of regulatory and other reporting requirements, the ability to multi-task and change focus quickly, and prioritize work accordingly to ensure the accuracy and integrity of reports. Individuals with strong organizational, technical, data visualization and reporting skills are encouraged to apply.
Responsibilities
Primary Job Responsibilities
• Perform departmental reporting and analyze data for trending, issue resolution, and opportunities for efficiencies.
• Use Excel macros, Alteryx, SQL and Access to develop/update and run queries/reports and ensure integrity of the data.
• Understand data sources and the data to complete the reports and analyze the data with management.
• Evaluate and collate data with respect to CMS reporting and protocols.
• Execute departmental reports at the required frequency with implemented quality check workflows.
• Analyze and review data on a regular basis to ensure compliance and consistency.
• Communicate data outliers to Medicare Compliance management and as requested to business owners and leadership.
• Complete simple ad hoc reporting/queries as needed and in coordination with management staff.
• Special projects as assigned.
• Identify opportunities to innovate.
• Maintain and improve systems and processes to support Fallon Health’s Medicare compliance program and departmental activities, especially concerning the monthly Medicare & PACE Dashboards and Universe submissions.
• Understand, use, and translate data, including mastery of all required Program Audit universes.
• Analyze department and program information/data to identify trends and risks that are reported back to business areas and vendors for action.
• Convert complex subject matter to accessible information.
• Support and execute Medicare compliance program activities.
• Leverage technology to support assigned program activities.
• Maintain documentation of program activities in well-documented processes.
• Meet organizational and CMS deadlines.
• Perform data analysis and validation to ensure required accuracy and specifications.
• Engage with internal business areas and vendors as needed to address issues identified to ensure compliance with audit protocols and reporting.
• Coordinate CMS audit deliverables in collaboration from other Medicare Compliance team members to ensure timely and accurate submissions.
• Provide support during mock audits and CMS audits with the review of data and coordination of webinars and the supporting materials involved.
• Understand and communicate about what we do and why.
• Develop working understanding of organizational structure to enhance our Medicare compliance program.
• Collaborate with colleagues across departments with a responsive and respectful approach.
• Communicate effectively with internal and external partners.
• Be self-motivated, take initiative and engage in critical thinking while being task-oriented, with excellent follow through, patience and persistence.
• Possess excellent analytical and creative problem-solving abilities, a strong commitment to accuracy and attention to detail.
• Aptitude to work in a fast-paced environment, adapt to changing conditions, and meet deadlines.
• Proficient with standard office computing applications such as Word, Excel, Outlook or equivalent.
Qualifications
Education:
Bachelor’s degree in business, health care or related area or equivalent job experience
Experience
• 2-4 years of experience working in a healthcare or other highly regulated environment; or other relevant specialized experience, training or education
• 2 years Medicare Advantage experience preferred
• PACE requirements knowledge a plus
• Competent in SQL, Access, Word, Excel & PowerPoint. Alteryx knowledge a plus. Ability to execute queries. Proficient competences with data analytics, data accuracy, QC & data integrity. Excellent interpersonal, verbal and written communications skills.
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 Show more details...
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
The Medicare Compliance Analyst & Support Specialist position is an essential role within Fallon Health’s Medicare compliance program and includes activities such as the collection and review of data universes for accuracy to protocols, data analysis to identify risks and trends, developing data visualization and dashboards to portray information to Fallon Health Leadership up to the Audit & Compliance Committee of the Board. This position assists with the monitoring of Medicare compliance-related functions as well as audits from the Centers for Medicare & Medicaid Services (CMS). This position is responsible for completing all departmental reporting and project related tasks accurately and within all required timeframes, maintaining a working knowledge of CMS regulations related to audits and reporting, updating policies and processes as needed, and coordinating CMS audits with collaboration from other Medicare Compliance team members. The position requires excellent organizational skills, an understanding of the importance of regulatory and other reporting requirements, the ability to multi-task and change focus quickly, and prioritize work accordingly to ensure the accuracy and integrity of reports. Individuals with strong organizational, technical, data visualization and reporting skills are encouraged to apply.
Responsibilities
Primary Job Responsibilities
• Perform departmental reporting and analyze data for trending, issue resolution, and opportunities for efficiencies.
• Use Excel macros, Alteryx, SQL and Access to develop/update and run queries/reports and ensure integrity of the data.
• Understand data sources and the data to complete the reports and analyze the data with management.
• Evaluate and collate data with respect to CMS reporting and protocols.
• Execute departmental reports at the required frequency with implemented quality check workflows.
• Analyze and review data on a regular basis to ensure compliance and consistency.
• Communicate data outliers to Medicare Compliance management and as requested to business owners and leadership.
• Complete simple ad hoc reporting/queries as needed and in coordination with management staff.
• Special projects as assigned.
• Identify opportunities to innovate.
• Maintain and improve systems and processes to support Fallon Health’s Medicare compliance program and departmental activities, especially concerning the monthly Medicare & PACE Dashboards and Universe submissions.
• Understand, use, and translate data, including mastery of all required Program Audit universes.
• Analyze department and program information/data to identify trends and risks that are reported back to business areas and vendors for action.
• Convert complex subject matter to accessible information.
• Support and execute Medicare compliance program activities.
• Leverage technology to support assigned program activities.
• Maintain documentation of program activities in well-documented processes.
• Meet organizational and CMS deadlines.
• Perform data analysis and validation to ensure required accuracy and specifications.
• Engage with internal business areas and vendors as needed to address issues identified to ensure compliance with audit protocols and reporting.
• Coordinate CMS audit deliverables in collaboration from other Medicare Compliance team members to ensure timely and accurate submissions.
• Provide support during mock audits and CMS audits with the review of data and coordination of webinars and the supporting materials involved.
• Understand and communicate about what we do and why.
• Develop working understanding of organizational structure to enhance our Medicare compliance program.
• Collaborate with colleagues across departments with a responsive and respectful approach.
• Communicate effectively with internal and external partners.
• Be self-motivated, take initiative and engage in critical thinking while being task-oriented, with excellent follow through, patience and persistence.
• Possess excellent analytical and creative problem-solving abilities, a strong commitment to accuracy and attention to detail.
• Aptitude to work in a fast-paced environment, adapt to changing conditions, and meet deadlines.
• Proficient with standard office computing applications such as Word, Excel, Outlook or equivalent.
Qualifications
Education:
Bachelor’s degree in business, health care or related area or equivalent job experience
Experience
• 2-4 years of experience working in a healthcare or other highly regulated environment; or other relevant specialized experience, training or education
• 2 years Medicare Advantage experience preferred
• PACE requirements knowledge a plus
• Competent in SQL, Access, Word, Excel & PowerPoint. Alteryx knowledge a plus. Ability to execute queries. Proficient competences with data analytics, data accuracy, QC & data integrity. Excellent interpersonal, verbal and written communications skills.
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 Show more details...
schedule_type: Full-time
Overview
About Fallon Community Health Plan...
Founded in 1977, Fallon Community Health Plan is a nationally recognized, not-for-profit health care services organization. From traditional health insurance products available throughout Massachusetts for all populations, to innovative health care programs and services for independent seniors, FCHP supports the diverse and changing needs of all those it serves. FCHP has consistently ranked among the
Overview
About Fallon Community Health Plan...
Founded in 1977, Fallon Community Health Plan is a nationally recognized, not-for-profit health care services organization. From traditional health insurance products available throughout Massachusetts for all populations, to innovative health care programs and services for independent seniors, FCHP supports the diverse and changing needs of all those it serves. FCHP has consistently ranked among the nation’s top health plans, and is the only health plan in Massachusetts to have been awarded “Excellent” Accreditation by the National Committee for Quality Assurance for its HMO, Medicare Advantage and Medicaid products. For more information, visit fchp.org.
About Summit ElderCare:
Summit ElderCare is a medical, insurance, and social support program that helps older adults remain living in the community as an alternative to moving to a nursing home. They get personalized care and attention and comprehensive benefits.
Position Overview:
To support the overall management and administration of the electronic medical record (Nextgen ) and other selected shared applications utilized for the management of selected dually capitated models of care and coverage operated by the TAIP, LLC. The application specialist will work collaboratively with and under the direction of the Summit ElderCare Application Administrator to ensure ongoing alignment with the base Summit ElderCare architecture and vendor contract, ongoing system and database integrity and will act as the primary resource for TAIP development and support needs.
Responsibilities
• Monitor system performance to ensure integrity of information capture and reporting for selected TAIP LLC products.
• Manage and maintain role based access in accordance with FCHP, TAIP LLC and when applicable Summit ElderCare policies and procedures.
• Manage the formal change management process in collaboration with management to maintain system integrity, support business needs and compliance with applicable contractual and regulatory requirements.
• Monitor and manage assignment of licenses in accordance with vendor contracts, budget requirements and changing business needs.
• Proactively ensure that the TAIP, LLC EMR/PM (Nextgen) platform is maintained with the most current prescription, ICD-10 and NPA tools as well as other dictionaries and resources as directed by management.
• Support the management software upgrades including testing in collaboration with vendor, FCHP IT staff and TAIP LLC staff while ensuring business continuity.
• Maintain updated documentation of application architecture, role based access, user profiles and password management specific to TAIP, LLC.
• Support management of ongoing compliance with policies and procedures related to application architecture, maintenance, access, security and contractual business requirements.
• Periodically conduct audits of system back up procedures, user profiles, HIPPA compliant file transfers, accounting of disclosures and data integrity.
• Program and implement approved software changes, update relevant documentation and communicate approved system changes to users and support staff.
• Develop and produce routine and approved TAIP, LLC ad hoc reports
• Stay abreast of industry changes as well as changing business needs and recommend changes to optimize quality and efficiency.
• Support the development and rollout of application specific training for new and existing TAIP, LLC staff.
• Work collaboratively with management and FCHP IT staff to troubleshoot and resolve hardware and operating system issues.
• Monitor system performance, including help desk and other service requests from TAIP, LLC staff and proactively address identified issues.
• Assist with the preparation and the management of budgets related to systems support, as assigned.
• Support TAIP, LLC staff with National PACE Association and other regulatory submissions, as needed.
• Assist with facilitating approved integrations with key business partners and provider groups in collaboration with FCHP IT and others in compliance with vendor contracts, applicable policies and procedures and budgetary guidelines.
• Assist with other applications and support projects, as needed.
Qualifications
Education: A 4 year college degree in business, computer science or related field or significant relevant experience in application administration
Experience:
• A minimum of 3 years experience in a business environment preferably healthcare.
• A minimum of 2 years experience as an application specialist, preferably with an EMR application.
Job ID 3593
# Positions 1
Location US-MA-Worcester
Posted Date 2/12/2014
Category Information Technology Show more details...
About Fallon Community Health Plan...
Founded in 1977, Fallon Community Health Plan is a nationally recognized, not-for-profit health care services organization. From traditional health insurance products available throughout Massachusetts for all populations, to innovative health care programs and services for independent seniors, FCHP supports the diverse and changing needs of all those it serves. FCHP has consistently ranked among the nation’s top health plans, and is the only health plan in Massachusetts to have been awarded “Excellent” Accreditation by the National Committee for Quality Assurance for its HMO, Medicare Advantage and Medicaid products. For more information, visit fchp.org.
About Summit ElderCare:
Summit ElderCare is a medical, insurance, and social support program that helps older adults remain living in the community as an alternative to moving to a nursing home. They get personalized care and attention and comprehensive benefits.
Position Overview:
To support the overall management and administration of the electronic medical record (Nextgen ) and other selected shared applications utilized for the management of selected dually capitated models of care and coverage operated by the TAIP, LLC. The application specialist will work collaboratively with and under the direction of the Summit ElderCare Application Administrator to ensure ongoing alignment with the base Summit ElderCare architecture and vendor contract, ongoing system and database integrity and will act as the primary resource for TAIP development and support needs.
Responsibilities
• Monitor system performance to ensure integrity of information capture and reporting for selected TAIP LLC products.
• Manage and maintain role based access in accordance with FCHP, TAIP LLC and when applicable Summit ElderCare policies and procedures.
• Manage the formal change management process in collaboration with management to maintain system integrity, support business needs and compliance with applicable contractual and regulatory requirements.
• Monitor and manage assignment of licenses in accordance with vendor contracts, budget requirements and changing business needs.
• Proactively ensure that the TAIP, LLC EMR/PM (Nextgen) platform is maintained with the most current prescription, ICD-10 and NPA tools as well as other dictionaries and resources as directed by management.
• Support the management software upgrades including testing in collaboration with vendor, FCHP IT staff and TAIP LLC staff while ensuring business continuity.
• Maintain updated documentation of application architecture, role based access, user profiles and password management specific to TAIP, LLC.
• Support management of ongoing compliance with policies and procedures related to application architecture, maintenance, access, security and contractual business requirements.
• Periodically conduct audits of system back up procedures, user profiles, HIPPA compliant file transfers, accounting of disclosures and data integrity.
• Program and implement approved software changes, update relevant documentation and communicate approved system changes to users and support staff.
• Develop and produce routine and approved TAIP, LLC ad hoc reports
• Stay abreast of industry changes as well as changing business needs and recommend changes to optimize quality and efficiency.
• Support the development and rollout of application specific training for new and existing TAIP, LLC staff.
• Work collaboratively with management and FCHP IT staff to troubleshoot and resolve hardware and operating system issues.
• Monitor system performance, including help desk and other service requests from TAIP, LLC staff and proactively address identified issues.
• Assist with the preparation and the management of budgets related to systems support, as assigned.
• Support TAIP, LLC staff with National PACE Association and other regulatory submissions, as needed.
• Assist with facilitating approved integrations with key business partners and provider groups in collaboration with FCHP IT and others in compliance with vendor contracts, applicable policies and procedures and budgetary guidelines.
• Assist with other applications and support projects, as needed.
Qualifications
Education: A 4 year college degree in business, computer science or related field or significant relevant experience in application administration
Experience:
• A minimum of 3 years experience in a business environment preferably healthcare.
• A minimum of 2 years experience as an application specialist, preferably with an EMR application.
Job ID 3593
# Positions 1
Location US-MA-Worcester
Posted Date 2/12/2014
Category Information Technology Show more details...
via LinkedIn
posted_at: 10 days agoschedule_type: Full-time
Overview
Fantastic Call Center Opportunities with training, career path advancement, great benefits, paid time off, heath insurance and more...
• The REMOTE work model can commence after approximately 8-9 weeks of on-site training in Worcester, MA.
The Great Opportunity
It’s an exciting time to join Fallon Health as we experience growth and expansion with new services and products. There are many great opportunities within our organization
Overview
Fantastic Call Center Opportunities with training, career path advancement, great benefits, paid time off, heath insurance and more...
• The REMOTE work model can commence after approximately 8-9 weeks of on-site training in Worcester, MA.
The Great Opportunity
It’s an exciting time to join Fallon Health as we experience growth and expansion with new services and products. There are many great opportunities within our organization starting with joining our Member Services team. Member Services offers a very unique opportunity to interact with nearly every facet of the Fallon Health organization including our products, services, functions, and people.
Among the most rewarding and fulfilling parts of working on this team is representing Fallon Health as the face of the organization; the single point of contact for our valued providers and members. Think of yourself as an Fallon brand and membership ambassador. As a representative of Fallon Health, you will be an advocate to members reaching out for support; providing this highly valued service fielding calls and constitutively troubleshooting inquiries, you will be solving their needs and concerns.
In addition to the diverse responsibilities outlined below, a spot on this team also represents one of the best places to grow your career. With demonstrated initiative and strong performance, you will gain exposure across a multitude of functions and endless opportunities for advancement. Member Services has proven to be a launching pad of development that has translated into long term careers with advancement opportunities throughout the company in a number of different key area’s such as; Sales and Marketing, Provider Relations, Care Services, Pharmacy and other functions of the operation.
As a brand champion and valued member ambassador you will get extensive training and support through a skill based progression training program that includes a blended learning curriculum and personalized coaching plan. We are always looking for top talent in these roles so feel free to pass this along to friends, family and colleagues that you think qualify.
Responsibilities
Position Overview:
The Member Services Representative is accountable for successfully addressing member and provider inquiries received through Fallon Health's 1-800 numbers, as well as providing direction on Plan policies, procedures, and benefits.
Some Key Responsibilities Include
• Ownership for development of knowledge and skills, as training program provides material and framework for success.
• Ownership for customer satisfaction. Member Service Representatives are the primary liaison for our members to obtain the information or support they need As such, our representatives are expected to fully understand member/ provider needs, and within corporate/ department policies, take whatever action is necessary to fully satisfy the inquiry.
• Clear and concise documentation of call detail for tracking of member/ provider contacts.
• Identification and communication of trends that are indicative of enterprise service issues.
• Escalation of member/provider concerns and servicing issues.
• Appropriate execution of corporate and department policies/ practices.
Qualifications
• High school diploma required, Bachelor’s degree or advanced education desirable
• 2+ years professional work experience preferably in a customer facing inbound call-center setting.
• The ability to multitask and leverage strong typing skills and a high proficiency with MS Word, MS Excel and system data entry are essential tools for success in this role
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 the only health plan in Massachusetts to have been awarded “Excellent” Accreditation by the National Committee for Quality Assurance for its HMO, Medicare Advantage and Medicaid products. For more information, visit www.fallonhealth.org
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.
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 Show more details...
Fantastic Call Center Opportunities with training, career path advancement, great benefits, paid time off, heath insurance and more...
• The REMOTE work model can commence after approximately 8-9 weeks of on-site training in Worcester, MA.
The Great Opportunity
It’s an exciting time to join Fallon Health as we experience growth and expansion with new services and products. There are many great opportunities within our organization starting with joining our Member Services team. Member Services offers a very unique opportunity to interact with nearly every facet of the Fallon Health organization including our products, services, functions, and people.
Among the most rewarding and fulfilling parts of working on this team is representing Fallon Health as the face of the organization; the single point of contact for our valued providers and members. Think of yourself as an Fallon brand and membership ambassador. As a representative of Fallon Health, you will be an advocate to members reaching out for support; providing this highly valued service fielding calls and constitutively troubleshooting inquiries, you will be solving their needs and concerns.
In addition to the diverse responsibilities outlined below, a spot on this team also represents one of the best places to grow your career. With demonstrated initiative and strong performance, you will gain exposure across a multitude of functions and endless opportunities for advancement. Member Services has proven to be a launching pad of development that has translated into long term careers with advancement opportunities throughout the company in a number of different key area’s such as; Sales and Marketing, Provider Relations, Care Services, Pharmacy and other functions of the operation.
As a brand champion and valued member ambassador you will get extensive training and support through a skill based progression training program that includes a blended learning curriculum and personalized coaching plan. We are always looking for top talent in these roles so feel free to pass this along to friends, family and colleagues that you think qualify.
Responsibilities
Position Overview:
The Member Services Representative is accountable for successfully addressing member and provider inquiries received through Fallon Health's 1-800 numbers, as well as providing direction on Plan policies, procedures, and benefits.
Some Key Responsibilities Include
• Ownership for development of knowledge and skills, as training program provides material and framework for success.
• Ownership for customer satisfaction. Member Service Representatives are the primary liaison for our members to obtain the information or support they need As such, our representatives are expected to fully understand member/ provider needs, and within corporate/ department policies, take whatever action is necessary to fully satisfy the inquiry.
• Clear and concise documentation of call detail for tracking of member/ provider contacts.
• Identification and communication of trends that are indicative of enterprise service issues.
• Escalation of member/provider concerns and servicing issues.
• Appropriate execution of corporate and department policies/ practices.
Qualifications
• High school diploma required, Bachelor’s degree or advanced education desirable
• 2+ years professional work experience preferably in a customer facing inbound call-center setting.
• The ability to multitask and leverage strong typing skills and a high proficiency with MS Word, MS Excel and system data entry are essential tools for success in this role
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 the only health plan in Massachusetts to have been awarded “Excellent” Accreditation by the National Committee for Quality Assurance for its HMO, Medicare Advantage and Medicaid products. For more information, visit www.fallonhealth.org
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.
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 Show more details...
via LinkedIn
schedule_type: Full-time
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
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.
Responsibilities
• Perform case reviews on medical records to identify quality of care or substandard care referred from incident reports, grievances, etc.
• Assist in the planning, organization and direction of the quality assessment performance improvement program and related activities.
• Assist in the evaluation of programs and implements changes as necessary to improve programs and assure compliance with regulatory requirements.
• Provide support with administrative functions such as form completion, writing reports, and submissions to management and/or appropriate agencies as required.
• Assist in the investigation of incidents, injuries, abuse, etc. Summarize findings and file reports to appropriate staff and agencies
• Oversee maintenance of clinical logs to manage data that supports clinical quality improvement, activities HPMS reporting and other external reporting requirements.Analyse clinical tracking logs and monitor for patterns and trends requiring corrective actions.
• Assist in developing annual auditing schedules for departments as well as audit development when identified.
• Coordinate studies performed within the quality assessment performance improvement program and prepares reports as required.
• Assist in the development and delivery of educational programs revolving around all components of quality assessment performance improvement, including orientation for employees and programs to address the quality assessment process and regulatory guidelines.
• Assist PACE organization sites in developing indicators and follow up procedures for identified problems
• Other duties as necessary
Qualifications
Education: Degree in nursing (Baccalaureate preferred) with a current MA nursing license
License: RN
Experience
5 years related experience in a healthcare setting preferably with a geriatric population
Quality Management/ Performance Improvement Experience Preferred
Knowledge of quality assessment and performance improvement procedures
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.
Fallon Health Vaccination Requirements
To protect the health and safety of our workforce, members and communities we serve, Fallon Health now requires all employees to disclose COVID-19 vaccination status. As of 2/1/2022 all roles not designated as “Remote” require full COVID-19 vaccination and Fallon Health will obtain the necessary information from candidates prior to employment to ensure compliance. Failure to meet the vaccination requirement may result in rescission of an employment offer or termination of employment Show more details...
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.
Responsibilities
• Perform case reviews on medical records to identify quality of care or substandard care referred from incident reports, grievances, etc.
• Assist in the planning, organization and direction of the quality assessment performance improvement program and related activities.
• Assist in the evaluation of programs and implements changes as necessary to improve programs and assure compliance with regulatory requirements.
• Provide support with administrative functions such as form completion, writing reports, and submissions to management and/or appropriate agencies as required.
• Assist in the investigation of incidents, injuries, abuse, etc. Summarize findings and file reports to appropriate staff and agencies
• Oversee maintenance of clinical logs to manage data that supports clinical quality improvement, activities HPMS reporting and other external reporting requirements.Analyse clinical tracking logs and monitor for patterns and trends requiring corrective actions.
• Assist in developing annual auditing schedules for departments as well as audit development when identified.
• Coordinate studies performed within the quality assessment performance improvement program and prepares reports as required.
• Assist in the development and delivery of educational programs revolving around all components of quality assessment performance improvement, including orientation for employees and programs to address the quality assessment process and regulatory guidelines.
• Assist PACE organization sites in developing indicators and follow up procedures for identified problems
• Other duties as necessary
Qualifications
Education: Degree in nursing (Baccalaureate preferred) with a current MA nursing license
License: RN
Experience
5 years related experience in a healthcare setting preferably with a geriatric population
Quality Management/ Performance Improvement Experience Preferred
Knowledge of quality assessment and performance improvement procedures
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.
Fallon Health Vaccination Requirements
To protect the health and safety of our workforce, members and communities we serve, Fallon Health now requires all employees to disclose COVID-19 vaccination status. As of 2/1/2022 all roles not designated as “Remote” require full COVID-19 vaccination and Fallon Health will obtain the necessary information from candidates prior to employment to ensure compliance. Failure to meet the vaccination requirement may result in rescission of an employment offer or termination of employment Show more details...
via LinkedIn
schedule_type: Full-time
Overview
Multiple needs at all of our five Summit ElderCare locations (Worcester, Lowell, Webster, Springfield, Leominster) and several shifts available - let us know what works best for you when you apply...
This is one of the better opportunities out there for Health Aides or CNAs and we will take great care of you! Why?..
• Great benefits!
• Full-time benefits offering!
• Health Insurance offerings!
• Paid Time Off!
• 10 Holidays!
•
Overview
Multiple needs at all of our five Summit ElderCare locations (Worcester, Lowell, Webster, Springfield, Leominster) and several shifts available - let us know what works best for you when you apply...
This is one of the better opportunities out there for Health Aides or CNAs and we will take great care of you! Why?..
• Great benefits!
• Full-time benefits offering!
• Health Insurance offerings!
• Paid Time Off!
• 10 Holidays!
• 401K Savings Plan!
• Tuition Assistance!
• Vision Care, Life Insurance and more!!
• *$20/hr to start and far exceeds state pay average! You can also make extra depending of the shifts you can work - read on!
• Extra pay for shifts outside normal workday!
• Extra $3.50/hr weekdays between 7pm and 7am Monday through Friday (shift ends Friday at 7am)
• Extra $4.00/hr for weekends beginning at 7pm on Friday and ending 7am on Monday.
• Mileage Reimbursement!
• Respectful and Desirable Health Aide / CNA Work Setting!
• Predictable Hours!
• Safe and highly vaccinated work environment including the member population you care for
• Our Health Aides and staff love the familiarity and relationships establishes with our members
• You will likely find more autonomy and flexibility than you have in your current role
• Our model is low-volume and very member and quality care focused
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.
About Summit ElderCare
Fallon Health operates the largest Program of All-Inclusive Care for the Elderly (PACE) in New England and the fifth largest in the country. Called Summit ElderCare, Fallon’s PACE helps provide older adults and their caregivers with a welcome alternative to nursing home care. Participants in Summit ElderCare have access to comprehensive medical services and social support at a Summit ElderCare site while they keep the independence of living in their own homes and communities.
Summary: Provides personal care, light housekeeping and assistance with ADLs (Activities of Daily Living) as outlined in each SE participant’s plan of care in participant homes as well as at the PACE center; exercises independent judgement; reports any changes in participant status to the IDT; participates in carrying out infection control precautions and increased cleaning and disinfecting of the PACE center as assigned and in accordance with current CDC guidelines
Responsibilities
• Under the supervision of the RN, assists with the Activities of Daily Living (ADL) needs of participants both at the PACE center and in participants’ homes (i.e., community, Assisted Living Facilities, Rest Homes, Supportive Housing programs, etc.)
• Contributes to the development of a care plan for participants through interaction with other members of the Interdisciplinary Team.
• Collaborates with members of the Interdisciplinary Team to assure appropriateness and continuity of care.
• Carries out non-skilled treatments including, but not limited to vital signs, transfers, toileting, bathing, dressing at the PACE Center and in the community.
• Assists the Supervisor, Recreational Activities and other activities staff with individual and group programs by helping to plan individual treatment programs, increasing participants’ motivation to participate, assisting participants to participate when needed, and assisting with evaluation of program effectiveness.
• Assists registered therapists and certified therapy assistants with treatments and participant-specific activities which are ordered for each participant and assigned by the registered therapist including, but not limited to, positioning, transfers, ambulation, and exercises.
• Maintains a clean and safe working and/or living environment in the PACE center and/or participants’ homes.
• Assists with meal and snack preparation, serving, feeding as needed, and clean-up.
• Uses safe techniques in all interactions with participants at the PACE Center and in participants’ homes.
• Provides accurate and timely documentation in the EMR and other systems as required by SE policies and procedures and/or as assigned by supervisor.
• Participates in carrying out schedule of daily cleaning and disinfecting of the PACE center in accordance with CDC guidelines for increased precautions
• Actively participates in distribution of work for health aides to ensure care needs of participants and site tasks are completed timely and appropriately including but not limited to community-based care and center-based tasks, as assigned
• Actively participates in regular team meetings for health aides at respective site
• Participates in carrying out infection control precautions and increased cleaning and disinfecting of the PACE center as assigned and in accordance with current CDC guidelines
• Performs all duties in accordance with FH and Summit ElderCare policies and procedures.
Qualifications
Education: Completion of an approved Home Health Aide or Certified Nursing Assistant Training Program
Certification: Certification as a Home Health Aide or Nursing Assistant
Experience
One year of experience working with a frail and/or older adult population preferably in a PACE program. If under one year, must complete Summit
Eldercare training program for health aides prior to working with participants independently.
Must complete a standardized set of Summit Eldercare competencies for Health Aides on an annual basis
Reliable transportation required.
Fallon Health Vaccination Requirements
To protect the health and safety of our workforce, members and communities we serve, Fallon Health now requires all employees to disclose COVID-19 vaccination status. As of 2/1/2022, all roles not designated as “Remote” require full COVID-19 vaccination and Fallon Health will obtain the necessary information from candidates prior to employment to ensure compliance. Failure to meet the vaccination requirement may result in rescission of an employment offer or termination of employment.
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 Show more details...
Multiple needs at all of our five Summit ElderCare locations (Worcester, Lowell, Webster, Springfield, Leominster) and several shifts available - let us know what works best for you when you apply...
This is one of the better opportunities out there for Health Aides or CNAs and we will take great care of you! Why?..
• Great benefits!
• Full-time benefits offering!
• Health Insurance offerings!
• Paid Time Off!
• 10 Holidays!
• 401K Savings Plan!
• Tuition Assistance!
• Vision Care, Life Insurance and more!!
• *$20/hr to start and far exceeds state pay average! You can also make extra depending of the shifts you can work - read on!
• Extra pay for shifts outside normal workday!
• Extra $3.50/hr weekdays between 7pm and 7am Monday through Friday (shift ends Friday at 7am)
• Extra $4.00/hr for weekends beginning at 7pm on Friday and ending 7am on Monday.
• Mileage Reimbursement!
• Respectful and Desirable Health Aide / CNA Work Setting!
• Predictable Hours!
• Safe and highly vaccinated work environment including the member population you care for
• Our Health Aides and staff love the familiarity and relationships establishes with our members
• You will likely find more autonomy and flexibility than you have in your current role
• Our model is low-volume and very member and quality care focused
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.
About Summit ElderCare
Fallon Health operates the largest Program of All-Inclusive Care for the Elderly (PACE) in New England and the fifth largest in the country. Called Summit ElderCare, Fallon’s PACE helps provide older adults and their caregivers with a welcome alternative to nursing home care. Participants in Summit ElderCare have access to comprehensive medical services and social support at a Summit ElderCare site while they keep the independence of living in their own homes and communities.
Summary: Provides personal care, light housekeeping and assistance with ADLs (Activities of Daily Living) as outlined in each SE participant’s plan of care in participant homes as well as at the PACE center; exercises independent judgement; reports any changes in participant status to the IDT; participates in carrying out infection control precautions and increased cleaning and disinfecting of the PACE center as assigned and in accordance with current CDC guidelines
Responsibilities
• Under the supervision of the RN, assists with the Activities of Daily Living (ADL) needs of participants both at the PACE center and in participants’ homes (i.e., community, Assisted Living Facilities, Rest Homes, Supportive Housing programs, etc.)
• Contributes to the development of a care plan for participants through interaction with other members of the Interdisciplinary Team.
• Collaborates with members of the Interdisciplinary Team to assure appropriateness and continuity of care.
• Carries out non-skilled treatments including, but not limited to vital signs, transfers, toileting, bathing, dressing at the PACE Center and in the community.
• Assists the Supervisor, Recreational Activities and other activities staff with individual and group programs by helping to plan individual treatment programs, increasing participants’ motivation to participate, assisting participants to participate when needed, and assisting with evaluation of program effectiveness.
• Assists registered therapists and certified therapy assistants with treatments and participant-specific activities which are ordered for each participant and assigned by the registered therapist including, but not limited to, positioning, transfers, ambulation, and exercises.
• Maintains a clean and safe working and/or living environment in the PACE center and/or participants’ homes.
• Assists with meal and snack preparation, serving, feeding as needed, and clean-up.
• Uses safe techniques in all interactions with participants at the PACE Center and in participants’ homes.
• Provides accurate and timely documentation in the EMR and other systems as required by SE policies and procedures and/or as assigned by supervisor.
• Participates in carrying out schedule of daily cleaning and disinfecting of the PACE center in accordance with CDC guidelines for increased precautions
• Actively participates in distribution of work for health aides to ensure care needs of participants and site tasks are completed timely and appropriately including but not limited to community-based care and center-based tasks, as assigned
• Actively participates in regular team meetings for health aides at respective site
• Participates in carrying out infection control precautions and increased cleaning and disinfecting of the PACE center as assigned and in accordance with current CDC guidelines
• Performs all duties in accordance with FH and Summit ElderCare policies and procedures.
Qualifications
Education: Completion of an approved Home Health Aide or Certified Nursing Assistant Training Program
Certification: Certification as a Home Health Aide or Nursing Assistant
Experience
One year of experience working with a frail and/or older adult population preferably in a PACE program. If under one year, must complete Summit
Eldercare training program for health aides prior to working with participants independently.
Must complete a standardized set of Summit Eldercare competencies for Health Aides on an annual basis
Reliable transportation required.
Fallon Health Vaccination Requirements
To protect the health and safety of our workforce, members and communities we serve, Fallon Health now requires all employees to disclose COVID-19 vaccination status. As of 2/1/2022, all roles not designated as “Remote” require full COVID-19 vaccination and Fallon Health will obtain the necessary information from candidates prior to employment to ensure compliance. Failure to meet the vaccination requirement may result in rescission of an employment offer or termination of employment.
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 Show more details...
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schedule_type: Full-time
• Overview****Fallon Health Vaccination Requirements:**To protect the health and safety of our workforce, members and communities we serve, Fallon Health now requires all employees to disclose COVID-19 vaccination status. As of 2/1/2022 all roles not designated as “Remote” require full COVID-19 vaccination and Fallon Health will obtain the necessary information from candidates prior to employment to ensure compliance. Failure to meet the vaccination
• Overview****Fallon Health Vaccination Requirements:**To protect the health and safety of our workforce, members and communities we serve, Fallon Health now requires all employees to disclose COVID-19 vaccination status. As of 2/1/2022 all roles not designated as “Remote” require full COVID-19 vaccination and Fallon Health will obtain the necessary information from candidates prior to employment to ensure compliance. Failure to meet the vaccination requirement may result in rescission of an employment offer or termination of employment.**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 www.fallonhealth.org .**Brief summary of purpose:** The Prior Authorization Nurseuses a multidisciplinary approach to organize, coordinate, monitor, evaluate and modify plans of care and/or service requests, focusing on selected complex medical and psychosocial needs of FH members and their families.**Responsibilities****The ideal candidate will be** someone that has some experience in direct patient care management, including admission, discharge planning also some experience with care coordination, including supplemental health care services, such as SNF discharge/placement (at least some knowledge). Plus have clinical data management, analyses and reporting.**Dischard Planning**+ Facilitate communications between the facility, providers, and the PCT in order to effect and influence a safe and effective discharge plan and care plan for the enrollee.+ Initiate the episodic plan of care that facilitates initation of the discharge plan for the inpatient or SNF setting.+ Work with facility case management department or specifically assigned staff to develop appropriate discharge plans; implements and continually reassesses the discharge plan.+ Collaborate with facilities, clinical team members and others involved in enrollee plan of care to ensure a smooth transition from facility to home setting for both assigned facility admissions and for program overall.**Clinical data management, analysis and reporting**+ Document clinical, functional, psychosocial information in the case management software system or Fallon Health core system. Facilitate communications regarding members’ care with PCT Team and family members.+ Identifies utilization trends or processes to Supervisor or Manager and supports the implementation of improvements.+ Review clinical information for concurrent reviews, extending the Length of Stay for inpatients as appropriate.+ Maintain accurate records of all interventions and provide timely verbal and written reports to PCT staff and associated family members as directed.+ Issue regulatory and other letters according to policies and procedures.+ Requests and obtains relevant clinical information from medical care providers as needed for the clinical review process.**Monitors compliance**+ Follow the Case Management Standards of Practice, Ethicial standards, department policies and procedures, and compliance regulations.+ Strictly observices HIPPA regulations and the Fallon Health polices regarding confidentiality of enrollee information, documentation standards, meeting any education requirements, etc.+ Refer cases to medical review according to policy and procedure.**Provides training and project management**+ Ensure Senior Nurse Case Managers are prepared and able to present enrollee data during rounds and huddles appropriately, teaching and mentoring as appropriate.+ Orients, precepts, and trains Senior Nurse Case Managers to ensure they are able to apply ocverage criteria in an appropriate manner.+ Supports department colleagues, covering and assuming changes in assignment as assinged by Clinical Manager/Designee.+ Acts as a resource to Authorization Coordinators:processes and /or consults on authorizations, as appropriate+ Participates in special projects including but not limited to training new team members, participating in projects related to software programs and others as assigned assoicated with the UM role and function.**Qualifications****Education** : **Graduate from an accredited school of nursing, or Bachelors (or advanced) degree in nursing??****License:** **Active and unrestricted licensure as a Registered Nurse in Massachusetts.****Experience:**+ A minimum of three to five years clinical experience as a Registered Nurse in a clinical setting required.+ 2 years’ experience as a Prior Authorization nurse in a managed care payer preferred.+ One year experience as a case manager in a payer or facility setting highly preferred.+ Discharge planning experience highly preferred.+ Prior authorizations for specialty meds and procedures, communication with insurance companiesand VNA for patient treatment**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.****JT18****Location** _US-MA-Worcester_**Posted Date** _1 month ago_ _(3/29/2022 4:57 PM)_**_Job ID_** _6797_**_\# Positions_** _1_**_Category_** _Nursing
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