Medicaid ACO Clinical Program Manager

Fallon Health - Worcester, MA3.5


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 the only health plan in Massachusetts to have been awarded “Excellent” Accreditation by the National Committee for Quality Assurance for its HMO, Medicare Advantage and Medicaid products. For more information, visit

Brief summary of purpose:
The ACO Clinical Project Manager will develop, implement, and manage clinical-focused projects for the Medicaid ACO, both internally within FH and externally with our ACO partners, to manage cost of care and patient outcomes for the Medicaid ACO program. The ACO Clinical Project Manager works closely with the FH Medicaid ACO Medical Director, as well as the Fallon Health (FH) VP of Quality and Population Health and other members of the Medicaid ACO team, and ACO partners to manage and monitor specific clinical initiatives.


Plan, develop, implement, manage, and monitor specific Model of Care clinical projects for the Medicaid ACO programs aimed at reducing cost of care and improving patient outcomes
Implement clinical program specific action plans, clinical work flows, strategies, and timelines
Actively manage and coordinate clinical project activities with the Medicaid ACO Medical Director, Quality Director, and shared services (utilization management, behavioral health, and case management functions)
Develop and sustain productive relationships with the FH ACO team
Develop and sustain productive relationships with the ACO partners and Community Partners, including regular visits to provide clinical guidance, support for implementation of specific initiatives, and training
Engage, educate, and support Medicaid ACO partners in appropriate and effective case management and utilization practices
Collaborate with the FH Medicaid ACO Medical Director and ACO partners to develop, implement, and monitor behavioral health focused initiatives
Apply expertise and serve as a resource to the FH and ACO teams on community supports, including LTSS and community/state supported behavioral health- and disability-related services
Develop relationships with key contacts at state agencies including MassHealth, DDS and DMH
Regularly gather and summarize relevant evidence-based literature and reports to guide Medicaid ACO Model of Care refinements
Develop familiarity with the use of technology to advance the quality and efficient delivery of care
Respond to clinical program specific inquiries and/or requests from the Medicaid ACO Medical Director
Collaborate with the ACO Clinical and Operations teams to develop solutions to complex clinical care situations. Participate in interdisciplinary care team discussions at FH to improve operations and overall optimal member care
Represent Fallon Health on externally facing work groups and work collaboratively with both internal and external teams comprising both clinical and non-clinical staff
Strictly observe HIPAA regulations and the Fallon Health Policies regarding confidentiality of member information

Demonstrate the following areas of proficiency including, but not limited to:

Ability to work with an interdisciplinary care team as a partner, demonstrating respect and value for all roles and serving as a positive contributor within job role scope and duties
Robust knowledge of Medicaid programs and the needs of Medicaid populations
Able to function independently to establish work plans and priorities
Team player, dedicated to the company’s mission and core values, with a track record demonstrating accountability for results
Have expertise on the clinical and care management of diverse low income populations
Strong management and interpersonal skills and ability to guide projects and programs across organizations and with multiple stakeholders
Have significant experience in leading multidisciplinary internal and external efforts
Be an effective liaison with providers and state and community agencies
Possess strong capability for on-the-ground-implementation
Ability to establish credibility and communicate professionally with primary care providers and other medical and service providers about program level issues as well as individual member level clinical status and needs
Be a strategic and analytic thinker
Be able to make decisions in a complex, changing environment
Basic facility with software systems including but not limited to Microsoft Office Products – Excel, Outlook, and Word



Bachelors or advanced degree in nursing or health care related field. Masters degree preferred (Nursing, MBA, MPH, etc.) OR graduate of a social worker program with a Masters degree in social work or psychology.

License: Active licensure as a Registered Nurse (RN) in Massachusetts OR Licensed Clinical Social Worker (LCSW) OR Licensed Independent Clinical Social Worker (LICSW) in Massachusetts

Other: Satisfactory Criminal Offender Record Information (CORI) results


A minimum of five years of experience in leading managed care, health care, or health policy programs focused on complex and vulnerable populations.
Previous direct experience with MassHealth programs.
Previous clinical program management experience requiring coordination across multiple stakeholders.
Expertise in the provision of case management services for complex vulnerable populations with social and behavioral health needs preferred.

Resources (systems, etc.) used in performing role

Microsoft Office products including but not limited to: Excel, PowerPoint, Word, Outlook, Visio, reporting software such as Business Objects, Boxer Application, QNXT, TruCare, and other applications

Physical Requirements of Role

Physical health sufficient to meet the ergonomic standards and demands of the position and the ability to transport self to member, provider, facility sites and locations. Valid Driver’s License and Clean Driving Record Required and a vehicle to be used for in-state travel.