Manager, Assessment RN

Overview

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 Assessment RN Manager provides strategic and operational leadership for multi-site assessment functions within Clinical Integration. The manager is accountable for timely, accurate, and compliant assessments; consistent application of clinical and program standards; workforce capacity and performance; and effective coordination across care management teams. This role leads supervisors and staff, translates regulatory and business requirements into reliable workflows, uses data to improve outcomes and efficiency, and ensures audit readiness across applicable product lines.

Responsibilities

Primary Job Responsibilities

Overview

• Ensure assessment operations consistently meet timeliness, accuracy, quality, and regulatory requirements.
• Build an effective leadership structure with clear accountability, coaching, succession planning, and staff readiness.
• Optimize staffing, workload distribution, productivity, and multi-site coverage based on member and business needs.
• Standardize assessment tools, workflows, documentation, and escalation pathways across product lines.
• Use performance data and root-cause analysis to improve outcomes, reduce rework, and strengthen audit readiness.
• Advance collaboration among Clinical Integration, care management, quality, compliance, state partners, and community providers.

Operational and People Leadership

• Lead assessment operations through supervisors and other designated team leaders, establishing clear priorities, decision rights, and performance expectations.
• Direct workforce planning, hiring, onboarding, deployment, coverage, and contingency planning for multi-site operations.
• Coach and develop supervisors; support performance management, corrective action, recognition, succession planning, and retention strategies.
• Monitor caseloads, queues, staffing capacity, and service demands; authorize workload rebalancing and escalation plans.
• Establish a consistent operating rhythm that includes leadership meetings, performance reviews, case escalation forums, and communication cascades.
• Promote an accountable, inclusive, member-centered culture focused on safety, service, continuous learning, and collaboration

Assessment Program Management

• Oversee the consistent use of MDS-HC, UAT, product-specific assessments, functional assessment tools, and related documentation standards.
• Ensure governance for MDS submissions, PCA time-for-task guidelines, rating category assignments, and whole-person care planning.
• Translate regulatory, contractual, and Model of Care requirements into operational workflows, training, job aids, and monitoring plans.
• Ensure assessment findings are communicated to appropriate care team partners and incorporated into coordinated member care planning.
• Lead response plans for assessment backlogs, workflow breakdowns, complex cases, and emerging operational risks.
• Partner with clinical and operational leaders on new programs, pilots, system changes, and process redesign affecting assessment teams.

Performance, Quality, and Compliance

• Define and monitor key performance indicators for timeliness, productivity, accuracy, quality, rework, and compliance.
• Use reporting and trend analysis to identify risks, variation, root causes, and improvement opportunities; hold leaders accountable for action plans.
• Oversee documentation audits, quality reviews, remediation, and validation of sustained improvement.
• Maintain operational readiness for NCQA, HEDIS, CMS, state, contractual, and internal audit requirements.
• Coordinate case-file preparation and management responses for audits, regulatory reviews, and corrective action plans.
• Ensure compliance with HIPAA, privacy, information security, clinical documentation, and organizational policies.

Cross-Functional and External Partnership

• Partner with Clinical Integration leadership, care management, navigators, utilization management, pharmacy, quality, compliance, analytics, operations, and information technology.
• Build collaborative relationships with members and personal representatives, state agencies, ASAP partners, vendors, contracted providers, and facilities as appropriate.
• Represent assessment operations in governance meetings, workgroups, implementation teams, and regulatory or partner discussions.
• Communicate operational performance, risks, resource needs, decisions, and recommended actions to senior leadership.
• Escalate member safety, access, compliance, and service risks promptly and ensure resolution ownership is clear.

Financial and Resource Stewardship

• Manage assigned resources responsibly and align staffing plans with approved budgets and operational priorities.
• Identify opportunities to improve efficiency, reduce avoidable rework, and use clinical resources at the appropriate level.
• Provide business rationale and operational impact analysis for staffing, technology, vendor, and process improvement needs.
• Monitor the operational impact of vacancies, overtime, incentives, travel, productivity variation, and changing service demand.

Qualifications

Qualification requirements Education RNs: Graduate from an accredited school of nursing, associates degree required, bachelor’s or higher preferred

License/Certifications

License: RN Candidates (Required) Active, unrestricted license as a Registered Nurse in Massachusetts

Certification: Certification in Case Management strongly desired, willingness to obtain when eligible

Other: Driving your personal motor vehicle is an essential job function of this position and the following requirements apply:

• Must possess a valid drivers’ license
• Must attest to no disqualifiers per Driver Safety Policy
• Must possess and provide proof of minimal state required auto insurance
• Must have reliable transportation

Experience

• A minimum of three years clinical experience as a licensed clinician managing/coordinating/facilitating/providing care for elders over the age of 65 required and experience working with other age population ages too required
• Two years of supervisory or management experience in a health care setting; preferably with experience supervising/managing a mix of clinical and non-clinical staff required
• Experience working in a healthcare setting as a member of a professional team coordinating care for adult populations who are diagnosed with health conditions or chronic disease, including mental illness of substance use disorders required
• Familiarity with in-home services both skilled and non-skilled, outpatient services including medical and behavioral health, knowledge of different levels of care including but not limited to acute, rehab, long term, and experience with Medicare and Medicaid coverage criteria and requirements required
• Three years’ experience performing care coordination in a managed care setting required
• Experience developing policies, procedures, and workflows required
• Experience with performance improvement projects including but not limited to establishing criteria for report queries, utilizing objective data to improve processes, and implementation of projects required
• Experience with improvement methodologies including but not limited to lean and six sigma a plus

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.