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Program Specialist, Clinical ACO Team
2 months ago
Overview:
About us:
Fallon Health is a company that cares. We prioritize our membersalwaysmaking 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 nations 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 programsincluding 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 Program Specialist, Clinical ACO Team:
- Understands and is a subject matter expert on the ACO State Contract keeping abreast with changes and modifications and relaying such to the ACO Clinical Leadership for updating policies, processes, and required actions
- Is an integral part of an interdisciplinary team focused on care coordination, care management and improving access to and quality of care for Fallon ACO members providing project management support and management of referral queues routing members for intervention to Care Team staff based upon established protocols
- Is the first point of contact to research member related requests using available documentation platforms and routing requests to the appropriate Clinical Team member to respond
- Works closely with the Clinical Leadership team organizing projects, attending meetings and taking notes, tracking deliverables, and keeping the Team focused on task deliverables and completion dates to ensure success
- Manages the Teams policies and processes working with Leaders and others that are subject matter experts to ensure policies and processes meet contractual requirements
- Research documents required during audits and State requests, preparing, editing, redacting documents requirements
- Understands the ACO Models of Care and acts as a support and resource for others on the Model
- Demonstrates very strong organizational, communication, and collaboration skills
Responsibilities:
Primary Job Responsibilities:
Operational Support
- Learns details in the State ACO Contract keeping abreast of changes and updates and is a resource to the Team and others on the Contract needs
- Manages the ACO Clinical Team policies and processes, ensuring compliance with the State Contract and working with leaders and subject matter experts to create and updates documents as necessary working in partnership with the Clinical Integration designee
- Attends meetings with team and leaders, takes minutes, tracks deliverables, and using organizational skills ensures the team is compliant meeting deadlines and required activities
- Assists with reporting and data needs helping the ACO Clinical Leaders and Partners with data requests and reports
- Leads ACO product line audits, coordinating, organizing, facilitating, and working with ACO Clinical Team Leaders to prepare documents for submission including but not limited to finding the appropriate document, preparing according to auditor protocols and working collaboratively to ensure the Teams successful outcome
- Works with ACO Clinical Leaders and partners associated with data reporting and requests helping ACO Clinical Leaders to respond to data and reporting requests to support the Program and the partner relationships
- Assists with scheduling requests and managing meeting calendars for the ACO Clinical Team Leaders
Member/Care Team Support
- Attends morning huddles with partners, taking notes of member specific needs and uses systems to assign members to Care Team members for interventions based upon established protocols managing queues as required
- Responds to initial requests from Customer Service and other Departments about members, researching, providing responses to questions and routing members to Care Team staff for interventions
- Acts as a primary liaison with Fallon Health Utilization Management Department, Appeals and Grievances, and Ombudsman to assist in resolving member-related issues
- Maintains an ongoing awareness of clinical, social, and financial resources available in the community. Maintains and organizes information on these resources to be utilized by ACO team
- Monitors TruCare ACO task queues and assigns tasks to ACO team as requested/ designated by ACO Leadership
- In conjunction with Medical Director/Director/designee, facilitates the Team with discharge planning for Program member situations as applicable
- Reviews and validates data on Member Panel report generated from the TruCare ensuring member contacts, programs, services are accurate and up to date at all times for members on panel
- Reviews claims and other reports monitoring for triggers and events that may warrant nurse case manager action (such as high dollar claims that may trigger a State assigned rating category change for NaviCare and ACO members) for members on panel
Other
- Supports department colleagues, covering and assuming changes in assignment as assigned by Director/designee
- Assists with orientation and training scheduling for new ACO team staff members
- Develops ACO product specific training modules working in conjunction with other subject matter experts and trains on the product as required
- May mentor and train staff on processes associated with job function and role.
- Organization and submission of success stories for the ACO team.
Education:
College degree (Bachelors degree) required. BA/BS in Health Services preferred.
Project Management Certification preferred.
Experience:
- 2+ years job experience in a managed care company, medical related field, or community social service agency required
- Understanding of hospitalization experiences and the impacts and needs after facility discharge required
- Knowledgeable about medical terminology and basic understanding of common disease processes and conditions required
- Knowledgeable about medical record documentation and able to recognize triggers requiring RN intervention required
- Knowledgeable about software systems including but not limited to Microsoft Office Products Excel, Outlook, and Word required
- Ability to learn and work in multiple software systems during the work day in order to accomplish tasks required
- 2+ years working in a supportive project management supportive role preferred
- 2+ years working with population health data to support programs preferred
- Experience interacting with providers and community partners preferred
- Experience working in a community social service agency, skilled home health care agency, community agency such as adult foster care, group adult foster care, personal care management agency, independent living agency, State Agency such as the Department of Mental Health (DMH), Department of Developmental Services (DDS), Department of Children and Families (DCF), and/or the Department of Youth Services (DYS), or other agency servicing those in need preferred
Resources (systems, etc.) used in performing role:
Microsoft Office products including but not limited to: Excel, PowerPoint, Word, Outlook; Visio, Business Objects, QNXT, TruCare, Collective Medical, and other applications including provider EMRs
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.
