Accreditation and Audit Director - Hybrid Remote

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:

With general direction from the Vice President and Senior Medical Director of Quality and Population Health, the Director of Accreditation and Audit ensures that the health plan is compliant with the National Committee for Quality Assurance standards, the regulations promulgated by the Centers of Medicare and Medicaid, the Massachusetts Division of Medical Assistance, and the Division of Insurance. This position is responsible to attain and maintain NCQA Health Plan Accreditation and NCQA Health Equity Accreditation and is responsible for continuous oversight to the accreditation process and will provide regular updates to senior leadership. This role develops and oversees a comprehensive workplan to ensure ongoing readiness for all accreditations and works closely with cross-functional teams to ensure compliance with NCQA, CMS and EOHHS. This position will keep abreast of changes in the regulatory environment to promote awareness with other directors and senior leaders, lead the subject matter experts and escalate issues as they arise.

Primary Job Responsibilities:

Leads all activities for NCQA Accreditation.
• Creates organizational awareness of the importance and value of NCQA Accreditation and ensures that it is reflected in the organization's daily operations.
• Manages the process of ongoing compliance and preparation for triennial accreditation reviews and ensures the health plan's compliance with all NCQA standards, including corporate policies and procedures that support the requirements.
• Ensures the health plan's compliance with NCQA, CMS, EOHHS.
• Develops and maintains the workplan to ensure timely completion of accreditation requirements.
• Responsible for the ongoing administrative, clinical, fiscal, and programmatic interaction with NCQA.
• Responsible for all communication with NCQA key contacts to ensure the organization is informed of all circumstances that impact the ongoing achievement of NCQA Accreditation.
• Reviews yearly NCQA standards and guidelines for changes and communicates changes to internal stakeholders.
• Provides timely and effective communication of project status and key milestones to all stakeholders.
• Monitors and ensures compliance with delegated functions across accredited products.
• Collaborates with the directors of corporate-wide functions such as quality improvement, credentialing, member rights, utilization management, including member appeals and grievances to support them in accreditation compliance.
• Implements cross functional teams to meet standard requirements for accreditation review and oversees the team's progress to ensure that timelines are met.
• Coordinates and oversees onsite or virtual accreditation and audit visits from regulatory bodies for the whole care services division.

Education:

• Bachelor's degree in health administration, public health, nursing or related field

Experience:

• Experience: Minimum of 5-7 years background in managed care and experience with national accreditation standards. Experience managing NCQA Health Plan Accreditation and NCQA Health Equity Accreditation. Strong leadership experience, critical thinking/problem solving skills and a strategic mindset. Strong writing and editing skills. Experience managing projects involving cross-departmental teams. Previous project management experience preferred.
• PC knowledge should include Microsoft software and database.

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.