Manager, Clinical Regulatory, Audit, and Accreditation
About The Position
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 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
- 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
- Accreditation & Audit Program Leadership
- Cross-Functional Regulatory Integration
- Quality Improvement & Risk Mitigation
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What This Job Offers
Job Type
Full-time
Career Level
Manager
