Fallon Massachusetts Jobs

mobile fallon logo

Job Information

Fallon Health Care Coordinator (Navigator) - ACO Team in Worcester, Massachusetts


The Care Coordinator (Navigator) - ACO Team is Remote!

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 Care Coordinator or Navigator 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.The Care Coordinator or Navigator partners with Fallon Health Care Team staff and other providers to communicate at all times what is occurring with the member and their status. The Care Coordinator or Navigator seeks to establish telephonic and face to face (depending upon product and circumstance) relationships with the member/caregiver(s) and provider partners to better ensure ongoing service provision and care coordination, consistent with the member specific care plan.In order to effectively advocate for member needs, the Care Coordinator or Navigator may make in home or facility visits (depending upon the product and circumstances) with or without other Care Team members to fully understand a member’s care needs.

Responsibilities include but are not limited to:

  • Utilizes an ACD line to support department and incoming/outgoing calls with the goal of first call resolution with each interaction

  • Conducting telephonic and may conduct face to face member visits to assess members utilizing TruCare Assessment Tools

  • Establishing and developing effective working relationships with community partners such as housing staff, adult day health care staff, assisted living staff, group adult foster and adult foster care staff, rest home staff, long term care facilities and other providers including primary care providers with the goal to facilitate member specific communication, represent Fallon Health in a positive and effective manner, and work to grow membership in the various Fallon Health products as applicable

  • Educating members/PRAs about their product specific benefits and how to access often times facilitating and coordinating such

  • Helps members to ensure physician office visits are scheduled and attended

  • Places referrals and following up to ensure services are in place as per the individual care plan and developing care plan in conjunction with the Care Team, preparing and sending member specific care plans per process


  • Member Education, Advocacy, and Care Coordination

  • Utilizes an ACD line to support department and incoming/outgoing calls with the goal of first call resolution with each interaction

  • Performs tasks and actions to ensure all CMS and State member related regulatory mandates are met including but not limited to welcome calls, care plans, health risk assessments/care needs screening for the member population, and member service plans according to Program Policy and Process for the particular member product

  • Provider Partnerships and Collaboration

  • May attend in person care plan meetings with partners and providers and leads care plan review with partners and providers and care team

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

  • Ensures accurate membership reports based upon provider/facility, distributes reports ensuring accuracy of data, updates and maintains provider sheets as applicable

  • Access to Care

  • Depending upon the product, generates requests and authorizations for Medicaid covered services per the member care plan ensuring all services requiring authorization have accurate and timely authorizations in place in the Fallon Health system with accuracy and timeliness per program process depending upon the member product and workflows

  • Educates members and providers on authorization processes, educates about authorization review outcomes, works to resolve authorization related issues and concerns depending upon the member product and workflows

  • Care Team Communication

  • Follows established transition of care workflow including but not limited to: communicating to all members of the Care Team when a care transition occurs and documents per workflow

  • Works collaboratively and ensures communication with members of the Care Team including but not limited to, medical providers, and member/PRAs to ensure member care plan supports their needs

  • Regulatory Requirements – Actions and Oversight

  • Depending upon member product, performs tasks and actions to ensure all CMS/State/NCQA related regulatory mandates are met including but not limited to Care Needs Screenings, Welcome Calls, Care Plans, Health Risk Assessments, and member Service Plans according to Program Policy and Process

  • Completes timely Care Needs Screening, Health Risk Assessments, Service Plans, and Care Plans in the TruCare system (care management platform) according to Regulatory Requirements and Program policies and processes


Education: College degree (BA/BS in Health Services or Social Work) preferred

License/Certifications: Current MA Driver’s License and reliable transportation. No certifications are required. 

Other: Satisfactory Criminal Offender Record Information (CORI) results.


  • 2+ years job experience in a managed care company, medical related field, or community social service agency required

  • 2+ years of experience working with people up to age 65 with a focus on working with people that are on MassHealth coverage and may be encountering social, economic, and/or multi complex medical and or behavioral health conditions required

  • Effective telephonic interviewing skills and the demonstrated ability to coordinate MassHealth benefits such as transportation through the State PT-1 process preferred

  • IF focused to work with the pregnant member population, 2+ years of experience working with pregnant females during the prenatal, delivery, and postpartum time working in conjunction with RNs coordinating care required

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.


Location US-MA-Worcester

Posted Date 3 weeks ago (11/11/2021 12:08 PM)

Job ID 6603

# Positions 1

Category Administrative/Clerical