Fallon Health

Director

• Provide strategic leadership and oversight responsibility for the clinical and operational utilization management activities for all inpatient and outpatient care, and staff across all product lines
• Oversees all administrative, operational and clinical functions related to outpatient and inpatient, utilization management operations, including but not limited to prior authorization, concurrent review and discharge planning
• Ensures that members get the appropriate care that is medically necessary and meets the benefit coverage criteria
• Ensures that all reviews meet the appropriate regulatory and accreditation requirements including turnaround times and communication
• Ensures program compliance with all federal regulatory and state mandates, Division of Insurance, National Committee for Quality Assurance standards, Centers for Medicare and Medicaid guidance and requirements, MassHealth (Medicaid contractual agreements)
• Responsible for hiring appropriate non-physician clinical and non-clinical personnel to review medical cases and determine if requests for services meet medical necessities and criteria for coverage
• Oversight of UM by delegated organizations and ensure regulatory and accreditation compliance
• Monitors and analysis of operational and outcome data related to all utilization management activities
• Recommends and implements innovative process improvements for the prior authorization and utilization management processes
• Develops and implements the Utilization Management Program Description and annually evaluate the effectiveness of the program
• Represents the UM Department in Program Audits across all LOBs, including information gathering, research, presenting, and development of Corrective Action Plans (if applicable)
• Key Contact for RFP responses related to UM Functions and department organization structure/staffing
• Works with VP/Medical Director to identify and prioritize the cost of care opportunities related to Utilization Management
• Works with VP/ Medical Director to set agenda related to UM and represent the plan at clinical joint operating committees to support collaborative Fallon/provider group relationship
• Manages data, predictive analytics to improve efficiency of prior authorization and utilization management
• Works with and represents Care Services for utilization management on the different product line task forces at Fallon
• Serves as SME and Point of Contact for internal committees including but not limited to Delegation Oversight Committee (DOC), Payment Policy, Mental Health Parity, Medical Directors monthly meeting, and TruCare Insights/upgrade meetings
• Represents the Vice President and Senior Medical Director of Clinical Management at internal and external senior level meetings
• Budget creation and management of annual budget
• Provides UM expertise to Clinical Integration leadership to ensure seamless integrated member care within Care Services as well as other departments by involving inpatient case management with out-patient case management and utilization management to optimize post-acute care
• Ensures objectives defined across a broader group are integrated and supportive where necessary
• Defines roles and accountabilities for staff, within the group and in the context of the broader process/operation in support of cross-functional efforts
• Hires for, develops and recognizes the experience and knowledge/skills/abilities required for a successful team
• Provides for the orientation and welcome of new staff
• Defines performance expectations and goals for staff
• Trains and mentors staff on the application of policy and procedures, use of supporting systems/applications, appropriate soft skills: time management, etc
• Monitors work of individual staff for efficiency, effectiveness and quality
• Provide ongoing constructive feedback and guidance to staff
• Evaluates staff on achievement of goals and deliverables and assessment of competencies
• Helps staff progress in their careers to the benefit of the department and broader organization
• Manages the resolution of performance issues in consultation with Human Resources as appropriate

RN Director, Utilization Management – Prior Authorization

Account Manager

• Serve as primary liaison between Fallon Health and contracted behavioral health vendor
• Lead weekly vendor account meetings to address operational needs
• Manage and oversee reporting packages from behavioral health vendors
• Collaborate with internal departments to promote behavioral health integration

Vendor Relations Manager

• Serve as the primary liaison between Fallon Health and its contracted behavioral health vendor
• Ensure seamless contract execution, operational excellence, and financial oversight across all lines of business
• Drive strategic partnerships, lead cross-functional initiatives, and promote behavioral health integration to improve member outcomes and vendor performance
• Lead weekly vendor account meetings to address operational needs and resolve issues
• Manage behavioral health provider contracts and maintain accurate documentation
• Develop and maintain vendor scorecards and performance metrics
• Identify and implement process improvements for vendor management
• Monitor and verify that the vendor consistently meets all compliance, regulatory, and contractual obligations as outlined in agreements
• Collaborate with the vendor and organizational leadership to proactively identify areas of concern or non-compliance, and address these through structured discussions during weekly account meetings
• Serve as department lead on cross-functional teams and subcommittees
• Coordinate with internal departments (Care Services, Claims, Credentialing, IT, Finance)

Behavioral Health Vendor Relations Manager

Manager

• Conduct a daily review of SUD Census reports and disseminate member-level information to assigned Fallon Care teams
• Collaborate with clinical teams of assigned SUD providers on treatment plans and discharge planning of members on inpatient units
• Works collaboratively and cohesively with all members of the care team (both internal and external staff and providers)
• Act as primary liaison with SUD facilities at all levels of care and community providers to assist with treatment planning as needed
• Monitor SUD HEDIS measures and identify opportunities for improvement
• Develops workflows and educates Team on workflows as appropriate

Substance Abuse Care Manager – LCSW, LICSW, LMHC, LADC preferred

• Provide strategic leadership and oversight for clinical and operational utilization management activities
• Oversee all administrative, operational and clinical functions related to outpatient and inpatient management
• Ensure program compliance with all federal regulatory and state mandates
• Responsible for hiring appropriate personnel to review medical cases
• Manage data and predictive analytics to improve efficiency
• Define performance expectations and goals for staff and monitor their work