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, we deliver equitable, high-quality coordinated care and are continually rated among the nation's top health plans for member experience, service, and clinical quality.

Fallon Health's NaviCare is a program for people age 65 and older, who live in our service area, and who have MassHealth Standard, and may have Medicare. It combines MassHealth (Medicaid) and Medicare benefits, including prescription drug coverage. At Fallon Health, 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- in the region. Learn more at fallonhealth.org or follow us on Facebook, Twitter and LinkedIn.

Brief Summary of Purpose:

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.

Job Responsibilities:

Member Assessment, Education, and Advocacy

Telephonically assesses and case manages a member panel
• May conduct in home face to face visits for onboarding new enrollees and reassessing members, utilizing a variety of interviewing techniques

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
• Demonstrates positive customer service actions and takes responsibility to ensure member and provider requests and needs are met

Regulatory Requirements - Actions and Oversight

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

Education:

• Graduate from an accredited school of nursing mandatory
• Bachelors (or advanced) degree in nursing or a health care related field preferred

License/Certifications:

• Active, unrestricted license as a Registered Nurse in Massachusetts; current Driver's license and reliable transportation
• Certification in Case Management strongly desired
• Satisfactory Criminal Offender Record Information (CORI) results

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

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.

COVID-19 Vaccination:

With the end of the Global Coronavirus COVID-19 Pandemic, Fallon Health no longer requires all employees to be vaccinated against COVID-19 except for employees who are in jobs that under state and federal laws, regulations and policies are required to be vaccinated and/or they are in Member/participant facing positions.