Job Information
Fallon Health Behavioral Health Regulatory and Quality Manager in Worcester, Massachusetts
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.
Responsibilities
Primary Job Responsibilities:
This position is responsible for ensuring Fallon Health’s (FH) accreditation of and compliance with behavioral health regulatory and compliance requirements for all lines of business including Community Care, Medicare, Medicaid ACO, and Duals programs.
Responsible for ensuring the plan is compliant with all federal and state agencies (including MA Executive Office Health & Human Services), regulatory standards and federal and state contracts regarding behavioral health services offered by the health plan.
Partner with Compliance area to ensure the integrity and success of compliance with the Mental Health Parity and Addition Equity Act (MHP).
Ensure that BH Material Subcontractor is compliant with all federal and state agency regulatory standards and acts as a liaison between Fallon and BH Vendor Compliance teams for all lines of business.
Co-Chair Fallon-BH Vendor compliance sub-committee
Represent behavioral health perspective in State Bulletins Workgroup. Responsible for behavioral health takeaways and communicating necessary changes to BH vendor and confirming through documentation back to the workgroup that the BH vendor has executed on requirements.
Ensure that EOHHS is informed of all events and circumstances that materially affect delivery of Behavioral Health Services or the management and administration of Behavioral Health services, including, without limitation, coordination of Behavioral Health Services and DMH (Department of Mental Health) Continuing Care Services. Ensure that the key contact is informed of such communication.
Proactively monitor NCQA, Medicare, MassHealth, Division of Insurance and Department of Mental Health to identify any changes in regulations, anticipate the effects these may have on Behavioral Health Programs, and help create strategies to prevent negative impact and promote change.
Plan and execute improvement steps to fully align with NCQA, Medicare, MassHealth, Division of Insurance and Department of Mental Health regulations.
Serve as BH subject matter expert on Privacy and Security Committee and collaborate with Privacy officer regarding HIPPA, 42 CMR and act as a liaison with BH vendor to ensure requirements are met.
Review and approve Behavioral Health reports produced by delegated entities and routinely report to the FH Delegation Oversight Committee on compliance to requirements and service standards according to the contractual agreement.
Fully understands and keeps abreast of changing program regulatory, compliance, accreditation, state contract and other needs with respect to Fallon Health’s Behavioral Health program and acting as a subject matter expert for all behavioral health regulatory questions.
Qualifications
Education:
Degree from an accredited school in psychology, social work, nursing, or healthcare administration. Masters preferred but not required
Experience:
Minimum of 5 years of experience in behavioral health managed care. Knowledge of federal and state requirements related to behavioral health for all lines of businsess including, MassHealth Medicaid, Medicare and Division of Insurance mandated requirements.
Experience with NCQA, CMS, and other required regulatory requirements and experience writing and developing policies and process documents required.
Experience presenting member files with Regulatory and Accreditation auditors
Experience developing corrective action plans and working with Program leadership and staff to implement and resolve issues identified in corrective action plans required for all lines of business.
Demonstrated proficiency including but not limited to:
Ability to develop and write policies; processes; program descriptions, and respond to requests for information from governmental agencies.
Ability to understand regulatory and accrediation requests and requirements, and collaborative work with department leaders to implement actions and workflows in a simple, reportable, and actionable way
Exceptional customer service skills and willingness to assist ensuring timely resolution.
Critical thinking skills for independent problem solving.
Fallon Health provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.
Location US-MA-Worcester
Posted Date 1 month ago (8/13/2024 2:16 PM)
Job ID 7678
# Positions 1
Category Administrative Support Workers