PACE Operations, Director

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 Director, PACE Operations, oversees PACE administrative operations for both Summit ElderCare (SE) and Fallon Health Weinberg PACE (FHW). This includes project management, administrative process and workflow development, and network capacity to ensure appropriate access to covered services for all PACE participants across the service areas.

This position works closely with leaders across functional areas to prioritize and implement key initiatives. The ideal candidate is an organized, proactive selfstarter with excellent communication skills, strong relationshipbuilding abilities, and comfort interacting with internal and external organizational leaders. Innovation, diplomacy, and attention to detail are essential.

Primary Job Responsibilities:

Collaborate with PACE and corporate leadership to define and prioritize PACE strategic projects and initiatives based on alignment with the Fallon Health strategic plan, financial considerations, and resource capacity.
• Maintain and update the PACE operational initiatives, responding to emerging needs and reporting progress to the PACE leadership team.
• Partner with leaders to evaluate and pursue new business relationships and growth opportunities. Conduct research, perform due diligence, and develop business cases informed by PACE program knowledge and marketplace trends.
• Lead project management activities for PACE growth initiatives from concept through execution, partnering with crossfunctional teams.
• Monitor and analyze relevant insurance and administrative regulatory requirements issued by NPA, CMS, and state agencies.
• Oversee premium and costshare billing processes, ensuring resolution of eligibility issues, accurate premium collection, and minimization of writeoffs.
• Collaborate with the Purchasing team to negotiate contracts and agreements for goods and services.
• Manage multiple projects simultaneously, maintaining focus on timelines, deliverables, and accountability.
• Work with Network Development & Management to ensure appropriate access to ancillary services across SE and FHW, including but not limited to in-home services, SNF, ALF, transportation, palliative care, and specialty services.
• Oversee vendor monitoring processes, including attestations, audits, corrective action plans, and timely resolution of deficiencies.
• Escalate outstanding attestation or audit findings to internal partners as appropriate.
• Oversee the Service Coordination Unit to ensure highquality customer service and timely procurement of inhome services for PACE participants.
• Serve as liaison to vendor partners, meeting regularly to review expectations, performance, and contract terms.
• Partner with Medicare Compliance to support internal monitoring and auditing activities.
• Work with the VP, Clinical Operations and VP/Medical Director to lead administrative processes and workflow development.
• Collaborate with PACE senior leadership and departments such as HR, Finance, IT, Claims, Billing & Enrollment, Contracting, and Provider Relations to resolve issues and pursue improvement opportunities.
• Ensure adherence to Fallon Health billing and financial policies by coordinating with Enrollment, Billing, MES (Medicaid Eligibility Services), and other internal teams.
• Ensure all new or revised PACE materials receive Corporate Communications approval and that only current approved materials are in use across all PACE sites.
• Drive and manage projects assigned by the VP, PACE Clinical Operations or other PACE leaders.
• Partner with IT to ensure necessary technology and telecommunications systems are available at PACE sites.

Education

• Bachelor's degree required; master's degree in business administration, Public Administration, Healthcare Administration, or related field preferred

Experience

• 6+ years' experience in the healthcare industry with expertise in operations planning, streamlining, and implementation.
• Demonstrated experience presenting to and collaborating with all levels of management, including Executive/CSuite.

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.