Associate Medical Director - Fallon Health

About us:

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

Summary of purpose: 

This position works with both inpatient and outpatient Care Management nurses to monitor appropriate care and services in hospitals, skilled nursing facilities and home care settings to ensure quality, cost-effectiveness and continuity of care. Also works with both inpatient and outpatient care managers on individual member cases to ensure the effectiveness of care management programs. Participates in physician reviewer and preauthorization meetings to coordinate and assure consistent application of FCHP guideline criteria; also to assure appropriate administration of member benefits as outlined in individual product line Evidence of Coverage Handbooks and the Benefits Manual.

Primary Job Responsibilities

• Provide clinical support for prior authorization process
• On-site, off-site and telephonic inpatient case management rounds
• Outpatient case management rounds
• Provider appeals review
• Member appeals review
• Pharmacy issues and referral requests
• Medical director on-call coverage
• Support the benefits and technology review process
• Provide support for UM administrative infrastructure
• Participate in the HP’s strategic planning process and establish yearly financial goals and monitor progress toward such goals as part of the strategic plan.
• Develop annual goals and objectives and submit to an annual evaluation by the President.

Education:

Unrestricted M.D degree with license to practice medicine in MA (or licensable).

License/Certifications:

Unrestricted MD degree with license to practice medicine in MA (or licensable).
Board certified in medical or surgical specialty.

Experience: 

Utilization management; network management; medical policy and technology experience. Demonstrated success and experience with Medicare Choice and Medicaid. History of or active participation in NCQA and CMS reviews. Experience in leadership position in healthcare-related position. Ability to manage external relationships. Ability to effectively utilize electronic resources, systems, and programs essential.

COVID-19 Vaccination:

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

Fallon Health provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.