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Fallon Health Fallon Health Weinberg – Nurse Care Manager in Amherst, NY, New York


About us:

Fallon Health Weinberg is a partnership between Fallon Health of Massachusetts and Weinberg Campus of Erie County, New York. Fallon Health Weinberg offers a Program of All Inclusive Care for the Elderly (PACE) and a Managed Long Term Care (MLTC) plan to serve the health needs of dual-eligible residents of the Western New York counties of Erie and Niagara.

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. Weinberg Campus has been providing needed services to the elderly for more than 100 years, through both community-based programs and nursing facility care. It is a renowned geriatric education and training institution offering the widest range of housing and care options available on one campus.

At Fallon Health Weinberg, 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.

Learn more at fallonweinberg.org or follow us on Facebook, Twitter and LinkedIn.

Brief Summary of Purpose:

The FHW Care Manager (CM) assesses a Members clinical/functional status and develops a plan to coordinate a continuum of care consistent with the Members health care needs and/or goals. The Individualized Care Plan (ICP) supports the Member attaining and/or maintaining an optimal functional status. The CM is an active participant in the Members Interdisciplinary Care Team (ICT) and is an advocate for the Member.

The CM is actively involved with the Member at times of care transition, including but not limited to planned and unplanned admissions, and works in conjunction with the members team to ensure care plan communication between all providers and members of the ICT. The CM coordinates care between multiple medical and Primary Care Team Providers. The CM is able to identify services, care delivery settings, and recommends alternatives where appropriate.

The CM monitors the care and provides consistent feedback to team on progress. The CM collaborates and works with all members of the Interdisciplinary Care Team and, when appropriate, the FHW care manager will work with Acute care hospitals, rehab facilities and skilled nursing facilities to ensure an effective care plan to meet member care needs. The CM may attend Facility Discharge Planning Rounds and works to ensure a smooth discharge and transition as appropriate. The CM’s assessment of multiple tools which can/will include MDS, UAS-NY and when necessary completion of these items will facilitate effective ICP’s and provide information for the ICT.

The CM will authorize/determine level of services for each member to include home care services. The CM is an advocate for members, and works to ensure the Member participates in the development and approval of their care plans as appropriate. The CM facilitates prompt and easy access to care appropriate to the disease or condition in line with applicable and appropriate clinical guidelines. The CM utilizes varied interviewing techniques including but not limited to motivational interviewing, and employs culturally sensitive strategies to engage and work with members. The CM goes to the members in the home and long-term care setting to assess needs and monitor progress towards patient agreed upon goals.


Job Responsibilities:

  • Reviews Member enrollment data, claims data, urgent and emergency room utilization, acute/skilled nursing inpatient census, referrals from Interdisciplinary Care Team (ICT) and vendors, and other appropriate data prior to initiating any Member contact

  • Contacts Members/caregivers telephonically and/or in person to at time of enrollment, at time of care transition, and/or ongoing based upon Program requirements to:

  • Perform a health needs assessment

  • Assess the health needs of the Members and/or

  • Recommend modifications to care plan elements

  • Completes a home visit/facility visit for all assigned Members as necessary, ideally within the first 60 days of members enrollment, any time there is a clinical change, or at intervals defined by FHW in order to determine member’s current needs.

  • Is a member of the assigned members ICT and attends all meetings.

  • Works closely with the Member’s team to initiate ICT meetings with ICT members/Members/caregivers as necessary and ensures the participation of appropriate interdisciplinary team members

  • As a member of the ICT, updates all relevant team members regarding the Member’s status and develops/proposes changes to the care plan

  • Identifies, aligns, and utilizes health plan and community resources that impact high-risk/high cost care

  • Creates contingency plans for each step of the process to anticipate treatment and service complications, while ensuring that the Member attains pre-determined outcomes

  • Streamlines the focus of the Member’s healthcare needs utilizing the most optimal treatment approach, promoting timely provision of care, enhancing quality of life, and promoting cost-effectiveness of care

  • Works collaboratively and cohesively with all members of the Primary Care

  • Utilizes a successful communication style and methods to engage Member’s in care management – does not ‘easily give up’ and works to engage Member’s as appropriate

  • Identifies and shares best practices and innovative care management strategies with the team

  • Supports department colleagues, covering and assuming changes in assignment as assigned by Supervisor/Designee

  • Strictly observes HIPPA regulations and the FHW policies regarding confidentiality of member information

  • Performs other responsibilities as assigned by the Supervisor/designee

  • Other tasks as identified



Graduate from an accredited school of nursing or Master’s Degree in social work required


  • Active, unrestricted license as a Registered Nurse in New York state

  • Certification in Case Management desired, encouraged upon hire


  • A minimum of three to five years clinical experience as a Registered Nurse or social worker working with the chronically ill, geriatric patients.

  • Minimum 2 years of experience in Home Health care setting working with Medicare/Medicaid required having demonstrated care coordination, accessing community resources a plus.

  • Experience working with patients/members in Long term care setting a plus.

  • Experience as a care manager within a payer setting with demonstrated ability to case manage 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.

Fallon Health Vaccination Requirements:

To protect the health and safety of our workforce, members and communities we serve, Fallon Health now requires all employees to disclose COVID-19 vaccination status. As of 2/1/2022 all roles not designated as “Remote” require full COVID-19 vaccination and Fallon Health will obtain the necessary information from candidates prior to employment to ensure compliance. Failure to meet the vaccination requirement may result in rescission of an employment offer or termination of employment.

Location US-NY-Amherst, NY

Posted Date 1 month ago (5/3/2023 4:57 PM)

Job ID 7290

# Positions 1

Category Nursing