Manager, Clinical Regulatory, Audit, and Accreditation

Fallon Health•Worcester, MA

About The Position

The Manager, Care Management Regulatory Compliance, Accreditation & Audit is accountable for enterprise compliance, accreditation readiness, and audit execution related to Care Management and Care Services operations. This role provides direct people leadership to Care Management Regulatory Managers while personally leading Fallon Health’s accreditation, regulatory audit preparation, and external survey activities across NCQA, CMS, EOHHS/MassHealth, and DOI. This role serves as the single point of accountability for translating regulatory and accreditation standards into operational practice, ensuring that Care Management documentation, workflows, staff competencies, and quality processes demonstrably meet all applicable requirements. The Manager functions as both a hands-on program leader and a strategic compliance advisor to senior leadership.

Requirements

Bachelor’s degree in health administration, public health, nursing or related health preferred. Master’s degree preferred
Experience: Minimum of 5- 7 years background in managed care and experience with national accreditation standards, regulatory requirements for Centers for Medicare and Medicaid, and the state of Massachusetts quality mandates. Experience managing NCQA surveys and CMS/MassHealth audits.
Prior people management experience, including coaching and performance management of regulatory or clinical staff.
Strong background in Care Management, care coordination, or clinical quality auditing.
Advanced project management and organizational skills
Exceptional written and verbal communication skills for regulatory submissions
Ability to translate regulatory standards into practical operational workflows
Advanced proficiency in Microsoft Office (Excel, Word, PowerPoint); experience with QNXT, TruCare, Business Objects preferred
Experience developing post audit 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 required
Experience with developing audit tools, auditing team member performance, and working with staff to improve their performance required
PC knowledge should include Microsoft software and database

Nice To Haves

Experience working in a Massachusetts Medicaid and/or Medicare Advantage environment preferred

Responsibilities

People Leadership & Oversight of CM Regulatory Staff
Provides direct supervision, coaching, and performance management for Care Management (CM) Regulatory Managers performing documentation audits, staff competency reviews, and regulatory monitoring
Establishes standardized audit methodologies, tools, and escalation pathways to ensure consistent regulatory interpretation and application across the CM team
Reviews audit findings produced by CM Regulatory Managers and ensures timely corrective action plans, follow-up monitoring, and sustained compliance improvement
Partners with Care Management leadership to address systemic performance gaps, training needs, and workflow redesign identified through audits and root cause analyses
Ensures staff maintain up-to-date knowledge of Fallon Health products, benefits, Evidence of Coverage, and CM policies
Ensures the care management division policies and processes are created and updated per corporate guidelines and reflect requirements from CMS, NCQA, and State requirements working in partnership with team and other leaders for accuracy and current state.
Accreditation & Audit Program Leadership
Personally leads Fallon Health’s accreditation and audit programs, serving as the primary project manager for NCQA surveys, CMS program audits, EOHHS/MassHealth reviews, DOI examinations, and related external oversight activities
Owns enterprise accreditation calendars, readiness plans, document repositories, and submission timelines, ensuring organizational preparedness at all times
Directly manages regulatory documentation, narratives, policies, procedures, and evidence submission to external regulatory and accrediting bodies
Coordinates and oversees onsite and virtual audit activities, including scheduling, staff preparation, real-time issue resolution, and post-audit remediation planning
Maintains expert-level knowledge of NCQA standards, CMS regulations, MassHealth/EOHHS requirements, and DOI mandates, proactively communicating regulatory changes and operational implications to senior leaders
Ensures that any NaviCare or Medicare Subcontractor is compliant with all federal and state agency regulatory standards
Understands the SCO Models of Care and acts as a support and resource for others on the Model
Cross-Functional Regulatory Integration
Collaborates with leaders across Care Management, Quality Improvement, Utilization Management, Appeals & Grievances, Credentialing, Compliance, Product, and IT to ensure regulatory requirements are operationalized consistently
Leads cross-functional workgroups to close accreditation gaps, implement regulatory changes, and sustain compliance over time
Serves as a trusted advisor to executive leadership on regulatory risk, audit readiness, and accreditation strategies
Quality Improvement & Risk Mitigation
Uses audit and accreditation findings to identify system-level quality improvement opportunities and supports leadership in prioritizing remediation efforts
Oversees root cause analyses related to regulatory deficiencies and ensure corrective actions are measurable, durable, and aligned with enterprise quality goals
Supports continuous improvement initiatives tied to member experience, documentation quality, and care management effectiveness