The Nurse Case Manager (NCM) is an integral part of an interdisciplinary team focused on care coordination, care management, and improving access to and quality of care for Fallon members. NCM seeks to establish telephonic and/or face to face relationships with the member/caregiver(s) to better ensure ongoing service provision and care coordination, consistent with the member specific care plan developed by the NCM and Care Team.
Responsibilities may include conducting in home face to face visits for member identified as needing face to face visit interaction and assessments with the goal to coordinate and facilitate services to meet member needs according to benefit structures and available community resources. The NCM may conduct assessments and may determine the number of hours' members require for MassHealth programs such as the personal care attendant program, adult foster care, group adult foster care, and other programs per product benefits and guidelines.
The NCM may utilize an ACD line to support department and incoming/outgoing calls with the goal of first call resolution with each interaction.
Education: Graduate from an accredited school of nursing mandatory and a Bachelors (or advanced) degree in nursing or a health care related field preferred.
License: Active, unrestricted license as a Registered Nurse in Massachusetts.
Certification: Certification in Case Management strongly desired.
Other: Satisfactory Criminal Offender Record Information (CORI) results and reliable transportation.
Experience: 1+ years of clinical experience as a Registered Nurse managing chronically ill members or experience in a coordinated care program required. Understanding of Hospitalization experiences and the impacts and needs after facility discharge required. Experience working face to face with members and providers preferred. Experience with telephonic interviewing skills and working with a diverse population, that may also be Non-English speaking, required. Home Health Care experience preferred. Effective case management and care coordination skills and the ability to assess a member's activities of daily function and independent activities of daily function and the ability to develop and implement a care plan that meets the member's need working in partnership with a care team preferred. Familiarity with NCQA case management requirements preferred.
Performance Requirements: Excellent communication and interpersonal skills with members and providers via telephone and in person. Exceptional customer service skills and willingness to assist ensuring timely resolution. Excellent organizational skills and ability to multi-task. Appreciation and adherence to policy and process requirements. Independent learning skills and success with various learning methodologies including but not limited to: self-study, mentoring, classroom, and group education. Working with an interdisciplinary care team as a partner demonstrating respect and value for all roles and is a positive contributor within job role scope and duties. Willingness to learn insurance regulatory and accreditation requirements. Knowledgeable about software systems including but not limited to Microsoft Office Products Excel, Outlook, and Word. Familiar with Excel spreadsheets to manage work and exposure and familiarity with pivot tables. Accurate and timely data entry. Effective case management and care coordination skills and the ability to assess a member's activities of daily function and independent activities of daily function and the ability to develop and implement a care plan that meets the member's need. Knowledge about community resources, levels of care, criteria for levels of care and the ability to appropriately develop and implement a care plan following regulatory guidelines and level of care criteria. Ability to effectively respond and adapt to changing business needs and be an innovative and creative problem solver.
Competencies: Demonstrates commitment to the Fallon Health Mission, Values, and Vision. Specific competencies essential to this position:
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.