
Job Information
Fallon Health Senior Care Options Nurse Case Manager - Lawrence/Lowell - Khmer preferred in Lawrence, Massachusetts
Overview
Our growing team is looking for a Senior Care Options Nurse Case Manager to work from home position while also doing visits to Navicare members in the Lawrence/Lowell area. Our ideal candidate would speak Khmer. Great salary and benefits inluded.
About NaviCare:
Fallon Health is a leader in providing senior care solutions such as NaviCare, a Medicare Advantage Special Needs Plan and Senior Care Options program. Navicare integrates care for adults age 65 and older who are dually eligible for both Medicare and MassHealth Standard. A personalized primary care team manages and coordinates the NaviCare member’s health care by working with each member, the member’s family and health care providers to ensure the best possible outcomes.
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.
Responsibilities
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, 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
Performs medication reconciliations
Performs Care Transitions Assessments – per Program and product line processes
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
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
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
Follows department and regulatory standards to authorize and coordinate healthcare services ensuring timeliness in compliance with documented care plan goals and objectives
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
Collaborates with appropriate team members to ensure health education/disease management information is provided as identified
Collaborates with the interdisciplinary team in identifying and addressing high risk members
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
Ensures members/PRAs participate in the development and approval of their care plans in conjunction with the interdisciplinary primary care team
Strictly observes HIPAA regulations and the Fallon Health Policies regarding confidentiality of member information
Supports Quality and Ad-Hoc campaigns
Care Coordination and Collaboration
Provides culturally appropriate care coordination, i.e. works with interpreters, provides communication approved documents in the appropriate language, and demonstrates culturally appropriate behavior when working with member, family, caregivers, and/or authorized representatives
With member/authorized representative(s) collaboration develops 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
Manages 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/authorized in the member’s care
Manages ACO members in conjunction with the Navigator, Social Care Managers, ACO Partners, Community Partners, Behavioral Health Partners and others involved/authorized in the member’s care
Monitors progression of member goals and care plan goals, provides feedback and works collaboratively with care team members and work effectively in a team model approach to coordinate a continuum of care consistent with the Member’s health care goals and needs
Works collaboratively with Fallon Health Pharmacist, referring members in need of medication review based upon Program process
Develops and fosters relationships with members, family, caregivers, PRAs, vendors and providers to ensure good collaboration and coordination by streamlining 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
Actively participates 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
Demonstrates positive customer service actions and takes responsibility to ensure member and provider requests and needs are met
Performs other responsibilities as assigned by the Manager/designee
Supports department colleagues, covering and assuming changes in assignment as assigned by Manager/designee
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
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/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
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
About Fallon Health:
Fallon Health is a mission-driven not-for-profit health care services organization based in Worcester, Massachusetts. For 45 years we have been improving health and inspiring hope in the communities we serve. Committed to caring for those who need us most, we pride ourselves on providing equitable access to coordinated, integrated care for our members with a special focus on those who qualify for Medicare and Medicaid. We also serve as a provider of care through our Program of All-Inclusive Care for the Elderly (PACE). Dedicated to delivering high quality health care, we are continually rated among the nation’s top health plans for member experience and service and clinical quality.
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-MA-Lawrence
Posted Date 1 week ago (1/17/2023 1:38 PM)
Job ID 7165
# Positions 1
Category Nursing