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 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.
Responsibilities
Note: Job responsibilities may vary depending on the member’s Fallon Health product.
Member Assessment, Education, and Advocacy
Telephonically assess and case‑manage a member panel.
May conduct in‑home face‑to‑face visits for onboarding new enrollees and reassessing members using a variety of interviewing techniques, including motivational interviewing, and employ culturally sensitive strategies.
Perform medication reconciliations.
Perform care transitions assessments per program and product line processes.
Utilize clinical judgment and nursing assessment skills to complete NaviCare Program Assessment Tools and Minimum Data Set Home Care (MDS HC) Form when a member’s medical/functional status changes.
Maintain up‑to‑date knowledge of program and product line benefits, plan evidence of coverage details, and department policies and processes, and follow policies to provide education to members and providers, including advocacy and member rights education.
Advocate for members to ensure they receive Fallon Health benefits and, if needs are identified but not covered, work with community agencies to facilitate access to transportation, food programs, and other services available through senior centers and other external partners.
Authorize and coordinate healthcare services ensuring timeliness in compliance with documented care plan goals and objectives.
Assess the member’s knowledge about the management of current disease processes and medication regimen, provide teaching to increase member/caregiver knowledge, and assist with self‑management of health, social, or behavioral health needs.
Collaborate with appropriate team members to ensure health education/drug management information is provided as identified.
Collaborate with the interdisciplinary team to identify and address high‑risk members.
Educate members on preventative screenings and other health care procedures such as vaccines and screenings according to established protocols and program processes, including key metrics outreach.
Ensure members/PRAs participate in the development and approval of their care plans in conjunction with the interdisciplinary primary care team.
Strictly observe HIPAA regulations and Fallon Health policies regarding confidentiality of member information.
Support quality and ad‑hoc campaigns.
Care Coordination and Collaboration
Provide culturally appropriate care coordination, working with interpreters and providing communications approved in the appropriate language.
With member/authorized representative(s) collaboration develop member‑centered care plans by identifying member care needs while completing program assessments and working with the Navigator to ensure the member approves their care plan.
Manage NaviCare members in conjunction with the Navigator, Behavioral Health Case Manager, Aging Service Access Point Geriatric Support Service Coordinator, contracted Primary Care Providers, and others involved in the member’s care.
Manage ACO members in conjunction with the Navigator, Social Care Managers, ACO Partners, Community Partners, Behavioral Health Partners, and others involved in the member’s care.
Monitor progression of member goals and care plan goals, provide feedback and work collaboratively with care team members; work effectively in a team model approach to coordinate a continuum of care consistent with the member’s health care goals and needs.
Work collaboratively with the Fallon Health Pharmacist, referring members in need of medication review based on program process.
Develop and foster relationships with members, family, caregivers, PRAs, vendors, and providers to ensure good collaboration and coordination by streamlining the focus of the member’s health care needs, promoting timely provision of care, enhancing quality of life, and promoting cost‑effectiveness.
Actively participate in clinical rounds.
Provider Partnerships and Collaboration
May attend in person care plan meetings with providers and office staff and may lead care plan review with providers and care team as applicable.
Demonstrate positive customer service actions and take responsibility to ensure member and provider requests and needs are met.
Regulatory Requirements—Actions and Oversight
Complete program assessments, notes, screenings, and care plans in the Centralized Enrollee Record according to product regulatory requirements and program policies and processes.
Possess knowledge of and compliance with HEDIS and Medicare 5 Star measure processes, performing member education, outreach, and actions in conjunction with the Navigator and other members of the Clinical Integration and Partner Teams.
Perform other responsibilities as assigned by the Manager/designee.
Support department colleagues, covering and assuming changes in assignment as assigned by Manager/designee.
Qualifications
Education: Graduate from an accredited school of nursing; a bachelor’s (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.
Outstanding Criminal Offender Record Information (CORI) results and reliable transportation.
Experience:
1+ years of clinical experience as an RN 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, including non‑English speaking, required.
Home Health Care experience preferred.
Effective case management and care coordination skills with the ability to assess a member’s activities of daily functioning and develop an individualized care plan 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 (self‑study, mentoring, classroom, group education).
Working with an interdisciplinary care team as a partner demonstrating respect and value for all roles and being a positive contributor within job role scope.
Willingness to learn insurance regulatory and accreditation requirements.
Knowledgeable about software systems including Microsoft Office (Excel, Outlook, Word) and familiarity with pivot tables.
Accurate and timely data entry.
Effective case management and care coordination skills with the ability to assess activities of daily function and develop a care plan that meets member needs.
Knowledge about community resources, levels of care, criteria for levels of care and ability to appropriately develop and implement a care plan following regulatory guidelines and level of care criteria.
Ability to 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.
Problem Solving
Asks good questions.
Critical thinking skills; looks beyond the obvious.
Adaptability
Handles day‑to‑day work challenges confidently.
Willing and able to adjust to multiple demands, shifting priorities, ambiguity, and rapid change.
Demonstrates flexibility.
Written Communication
Is able to write clearly and succinctly in a variety of communication settings and styles.
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.
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