Fallon Health ACO Care Manager - New career Join us at Fallon Health Insurance! in Worcester, Massachusetts
About Fallon Health
Founded in 1977, Fallon Health is a leading health care services organization that supports the diverse and changing needs of those we serve. In addition to offering innovative health insurance solutions and a variety of Medicaid and Medicare products, we excel in creating unique health care programs and services that provide coordinated, integrated care for seniors and individuals with complex health needs. Fallon has consistently ranked among the nation’s top health plans, and is accredited by the National Committee for Quality Assurance for its HMO, Medicare Advantage and Medicaid products. For more information, visit fallonhealth.org.
Brief summary of purpose
The ACO Care Integration Manager will provide important care coordination and care management function across Fallon Health teams, Accountable Care Organizations (ACOs), Community Partners (CPs) and other entities in the management of Fallon’s Medicaid ACO members with medical and/or behavioral health complexity.
Primary Job Responsibilities
Provide care coordination and care management activities in support of Fallon Health’s Medicaid ACO members
Serve as a resource to internal Fallon Health teams including, but not limited to, the UM, case management, Pharmacy, behavioral health, and ACO teams, on the identification of high need members and the available medical, behavioral health, long term services and supports (LTSS), and community resources to support Fallon’s ACO members
Coordinate across internal staff and Fallon Health’s ACOs, Community Partners, behavioral health vendor, EOHHS agencies, and other entities both on individual complex cases and on broader strategic ACO initiatives
Provide input into the Fallon Health ACO model of care and identify tactical and systems issues for improving the care of Medicaid ACO members with medical and behavioral health complexity, including those impacted by the social determinants of health (SDHs) and/or with multi-system or multi-agency involvement (e.g., DDS, DMH, etc.).
Provide input into the ACO transitions of care assessment, and--in collaboration with Fallon Health internal teams, behavioral health vendor, the ACOs and CPs--manage transitions of care of medically and/or behaviorally complex cases, and/or those impacted by SDHs or multi-agency involvement
Assess a member’s clinical/functional/behavioral health status and use this information to provide case management and care coordination for the member across the continuum of care which is consistent with a member’s health care needs and goals
Develop, interpret and use case-specific and aggregate data analyses to identify high needs members; to inform member-specific interventions; to identify potential systems changes, efficiencies, cost savings and quality improvement opportunities; and to support recommendations for workflow and process improvements among Fallon Health, the ACOs and the CPs.
Demonstrate facility with and apply claims data and medical records to enhance care coordination, improve service delivery, and effect clinically appropriate and cost effective treatment plans for Fallon Health ACO’s most complex members
Provide care management leadership and subject matter expertise to interdisciplinary teams and initiatives
Represent Fallon Health on externally facing work groups, develop a strong relationship with ACOs and CPs, and workcollaboratively with both internal and external teams comprising both clinical and non-clinical staff.
Demonstrate knowledge of the Fallon Health ACO benefits and apply coverage criteria, payment policy, and MassHealth regulations when coordinating care and educating other Fallon Health, ACO, or CP team members about benefits, qualifications, and coverage criteria.
Provide culturally appropriate care coordination, i.e., work with interpreters, provide communication approved documents in the appropriate language, and demonstrate culturally appropriate behavior when working with member, family, caregivers, and/or authorized representatives
Manage Care Transitions:
Work closely with the Fallon Health UM Team, which closely monitors the daily inpatient census, to learn when a member has a care transition
Communicate and coordinate member care needs and discharge plans with Fallon Health Utilization Management staff
Participate in discharge planning discussions to ensure member care needs are met before and after discharge
Follow up with Fallon Health, ACO and CP teams telephonically or in person after discharge to ensure that Transition of Care assessments and medication reconciliation are completed, and that services are in place as care planned within designated time frames Work collaboratively with Fallon Health Pharmacist, referring members in need of medication review based upon Program process
Develop and foster relationships with Fallon Health internal teams, ACOs, CPs, members, family, caregivers, Personal Representative Authorization designees (PRAs), vendors and other 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
Contribute to the implementation and modification of the ACO Models of Care and to trainings/orientations with ACO and CP staff, further defining the various roles of the respective partners in the coordination of member’s care
Perform and, as required, may lead face to face or in-person member care plan review with providers and other key stakeholders including, but not limited to, ACO Providers, CPs, LTSS Providers, Behavioral Health Providers, Long Term Care Facility Providers, and EOHHS agency representatives, such as DDS service coordinators and/or any other Provider/Member/Authorized Representatives, to ensure effective communication and collaboration between all involved
Partner with interdepartmental teams (including but not limited to: Utilization Management, Appeals and Grievance, ACO, Provider Relations, Pharmacy, Behavioral Health Leadership) within Fallon Health to ensure that provider/member satisfaction is maintained while articulating issues to help to facilitate problem/issue resolution
Strictly observe HIPAA regulations and the Fallon Health Policies regarding confidentiality of member information
A minimum of four years of case management experience managing Medicaid/disabled patients or experience in a coordinated care program servicing the needs of Medicaid and disabled populations preferred.
Experience with addressing behavioral health issues and social determinants of health and linking members to community resources to address these needs
Demonstrate the following areas of proficiency including, but not limited to:
Ability to work with an interdisciplinary care team as a partner, demonstrating respect and value for all roles and serving as a positive contributor within job role scope and duties
Robust knowledge of Medicaid programs and the needs of Medicaid and disabled populations
Strong familiarity with EOHHS agency (e.g., DDS, DMH, etc.) eligibility processes and programs
In depth knowledge of long terms services and supports (e.g., home health care, AFC, PCA, etc.) in order to apply coverage criteria for home health care and to assess for referral to programs, such as personal care attendant, group adult foster care, adult foster care, and other long term services in supports in collaboration with Fallon Health’s internal teams, ACOs, and CPs
Knowledge about 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 establish credibility and communicate professionally with primary care providers and other medical and service providers about a member’s clinical status and needs
Ability to organize, schedule, and prioritize to meet the requirements of the position
Exceptional customer service skills and willingness to assist in timely resolution of issues
Ability to effectively respond and adapt to changing business needs and be an innovative and creative problem solver
Independent learning skills and success with various learning methodologies including, but not limited to: self-study, mentoring, classroom, and group education
Basic facility with software systems including but not limited to Microsoft Office Products – Excel, Outlook, and Word
Job ID 5353
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