Manager, Pace Operations Support - Worcester, United States - Fallon Health

Fallon Health

Verified Company

Worcester, United States

3 weeks ago

Posted by:

Mark Lane

beBee recruiter

Description

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.

Brief summary of purpose:

The Manager works closely with their counterpart to assist the Senior Director, PACE Operations to manage the program level operational and regulatory functions related to Fallon Health's PACE programs.

Responsible for compiling reports and analyzing data and making program level recommendations.

The Manager supports the Senior Director, PACE Operations to manage program level operational and regulatory functions in support of the program's quality, strategic and financial goals.

Responsible for supporting PACE sites related to the development and implementation of processes and workflows, network development, contract management, claims, billing, and authorization assistance.

This position requires regular travel to all Summit ElderCare sites and occasional travel to FHW PACE to provide support/guidance on various operational topics.

Travel = 10% of the time

Responsibilities:

Primary Job Responsibilities

Is responsible for ensuring accurate payment of the PACE medical claims:

Responsible for managing the SE QNXT claim inventory
Responsible for following up with Supervisors of Support Staff to ensure that the pended claims are being processed timely
Responsible for reviewing authorization issues that result in incorrect payment and working with site staff to resolve issues in a timely manner
Responsible for ensuring that necessary training is conducted so that office staff is able to complete daily billing and claims responsibilities
Works with FH UM, Provider Relations, and Claims departments to troubleshoot authorizations and claims issues

Is responsible for overseeing the PACE Service Coordination Unit:

Responsible for managing and supervising the SE Service Coordinators
Responsible for ensuring SE Service Coordinators are working quickly to secure needed home care services for PACE participants
Responsible for conducting random call audits on a regular basis to ensure quality customer service and appropriateness of call content
Responsible for ensuring that necessary onboarding, training, ongoing regular supervision/touchpoints and, if needed, performance management, is carried out with all Service Coordinators
Has regular communication with external home care vendors and Service Coordination Unit to ensure good business partnerships
Works with site teams to ensure Service Coordination unit receives the needed information in order to secure appropriate inhome services for PACE participants

Committees & Workgroups:

For assigned meetings, prepares agenda in collaboration with Senior Director, PACE Operations
Responsible for meeting follow ups
Records meetings, documents key points and necessary follow up, sends out link to meeting minutes in a timely manner to all attendees

PACE Member Satisfaction:

Reviews monthly SE satisfaction surveys
Responsible for following up with the sites to resolve participant and caregiver issues/concerns
Attends the monthly FH Service Advisory Committee meeting as PACE representative and reports on satisfaction survey scores below 9 as well as other Service Quality related topics
Attends SE Service Quality Meeting quarterly and works with SE leadership and PACE sites to plan interventions and improvement activities for increasing Participant satisfaction scores, reports back to FH Service Advisory Committee

Conduct systemic monitoring of pended claims inventory:

Communicates with relevant PACE sites and monitors for resolution
Strives to improve processes while leveraging assistance and resources from other Fallon Health departments
Support ongoing adherence to Summit ElderCare billing policies and procedures
Ongoing interaction and coordination with FH Enrollment and Billing Operations, Medicaid C