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Fallon Health Associate Medical Director in Worcester, Massachusetts


About Fallon Health

Founded in 1977, Fallon Health is a leading health care services organization that supports the diverse and changing needs of those we serve. In addition to offering innovative health insurance solutions and a variety of Medicaid and Medicare products, we excel in creating unique health care programs and services that provide coordinated, integrated care for seniors and individuals with complex health needs. Fallon has consistently ranked among the nation’s top health plans, and is accredited by the National Committee for Quality Assurance for its HMO, Medicare Advantage and Medicaid products. For more information, visit fallonhealth.org.

Brief summary of purpose: This position works with both inpatient and outpatient Utilization Management nurses to oversee appropriate care and services in hospitals, skilled nursing facilities and home care settings to ensure quality, cost-effectiveness and continuity of care. Also works with both inpatient and outpatient care managers on individual member cases to ensure the effectiveness of care management programs. Participates in physician reviewer and preauthorization meetings to coordinate and assure consistent application of FH guideline criteria; also to assure appropriate administration of member benefits as outlined in individual product line Evidence of Coverage Handbook and the Benefits Manual. Provides both clinical and administrative support for Care Services programs, e.g. CM, UM, Pharmacy, Quality. Provides clinical support for non-Care Services programs; NDM, Claims, IT, Sales, etc.


Utilization Management -50%

  • Inpatient, Outpatient Services, Molecular Diagnostics, Post-Acute Care, Post-service clinical review: DRG validation, Fraud/Waste/Abuse

  • Provides leadership, content and direction to case/care management contingencies.

  • Provides leadership, content and direction to utilization management contingencies

  • On-site, off-site and telephonic inpatient case management rounds

  • Outpatient case management rounds

  • Provide clinical support to Provider and Member Appeals

  • Provide clinical and administrative support to NDM Department

Medical and Payment Policy -20%

  • Provide clinical support to development of medical and payment policies.

  • Provide clinical support to development of coverage and coding policies and clinical review of provider appeals related to coding issues

Provider Profiling -<5%

  • Contributes to provider reporting initiatives.

  • Participates in profiling discussions and appeals with network MDs

HEDIS/Quality Improvement - <5%

  • Contributes to performance improvement initiatives

  • Monitors and provides feedback to QI initiatives

Committee Chair/Coordination ->10%

  • Responsibilities include participation in or leadership of Care Services Committees as assigned by the Medical Director or Chief Medical Officer. (may include P&T, Credentialing, TAC, CQIC, BOC, DOC, COC, PPC, Claim Check Steering Committee)

  • Reporting

  • Agenda Setting

  • Charter Oversight

  • Maintenance of Staffing

External Representation -<5%

  • Represent Fallon Health interests to provider, community, trade association or multi-stakeholder group as assigned by Senior Medical Director or Chief Medical Officer.

Medical Director on-call coverage- Up to 6X annually

  • Weekend on-call coverage


  • Participate in the FH’s strategic planning process and establish yearly financial goals and monitor progress toward such goals as part of the strategic plan

  • Develop annual goals and objectives and submit to an annual evaluation

  • Provides leadership and/or direction of Fallon Health interdepartmental committees

  • Special projects as assigned by Medical Director or Chief Medical Officer


Education, Licenses, certification and experience requirements


  • MD or DO degree from accredited medical school


  • Unrestricted license to practice medicine in MA (or licensable).

  • Board certified in medical or surgical specialty.


Utilization management; medical policy and technology experience; vendor management experience. Demonstrated success and experience with Medicare and/or Medicaid. Experience in administrative medicine or leadership position in healthcare-related position. Ability to manage external relationships. Ability to effectively utilize electronic resources, systems and programs essential. Active practice in a clinical subspecialty is highly desirable.

Resources used in performing role:




MS Office (Excel, Word, Outlook, PowerPoint)

Electronic Medical Resources (PubMed)

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.

Location US-MA-Worcester

Posted Date 1 month ago (4/13/2021 5:51 PM)

Job ID 6325

# Positions 1

Category Medical Management