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.

MEMBER ASSESSMENT, EDUCATION, AND ADVOCACY

o Telephonically assesses and case manages a member panel
o May conduct in home face to face visits for onboarding new enrollees and reassessing members, utilizing a variety of interviewing techniques, including motivational interviewing, and employs culturally sensitive strategies to assess a Member’s clinical/functional status to identify ongoing special conditions and develops and implements an individualized,coordinated care plan, in collaboration with the member, the Clinical Integration team, and Primary Care Providers, Specialist and other community partners, to ensure a cost effective quality outcome
o Performs medication reconciliations
o Performs Care Transitions Assessments – per Program and product line processes
o Utilizing clinical judgment and nursing assessment skills, may complete NaviCare Program Assessment Tools and Minimum Data Set Home Care (MDS HC) Form when a member’s medical/functional status changes that warrants a change in rating category to ensure members are in the correct State defined rating category
o Maintains up to date knowledge of Program and product line benefits, Plan Evidence of Coverage details, and department policies and processes and follows policies and processes as outlined to be able to provide education to members and providers; performing a member advocacy and education role including but not limited to member rights
o Serves as an advocate for members to ensure they receive Fallon Health benefits as appropriate and if member needs are identified but not covered by Fallon Health, works with community agencies to facilitate access to programs such as community transportation, food programs, and other services available through senior centers and other external partners
o Follows department and regulatory standards to authorize and coordinate healthcare services ensuring timeliness in compliance with documented care plan goals and objectives
o Assesses the Member’s knowledge about the management of current disease processes and medication regimen, provides teaching to increase Member/caregiver knowledge, and works with the members to assist with learning how to self- manage his or her health needs, social needs or behavioral health needs
o Collaborates with appropriate team members to ensure health education/disease management information is provided as identified
o Collaborates with the interdisciplinary team in identifying and addressing high risk members
o Educate members on preventative screenings and other health care procedures such as vaccines, screenings according to established protocols and program processes such initiatives involving Key Metrics outreach
o Ensures members/PRAs participate in the development and approval of their care plans in conjunction with the interdisciplinary primary care team
o Strictly observes HIPAA regulations and the Fallon Health Policies regarding confidentiality of member information
o Supports Quality and Ad-Hoc campaigns

REGULATORY REQUIREMENTS – ACTIONS AND OVERSIGHT

o Completes Program Assessments, Notes, Screenings, and Care Plans in the Centralized Enrollee Record according to product regulatory requirements and Program policies and processes

o 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

• Performs other responsibilities as assigned by the Manager/designee
• Supports department colleagues, covering and assuming changes in assignment as assigned by Manager/designee

Qualifications:

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 INCLUDING BUT NOT LIMITED TO:

• 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

The Nurse Case Manager (NCM) is an integral part on 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.
Responsibilities:
Note: Job Responsibilities may vary depending upon the member’s Fallon Health Product