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Fallon Health Clinical Integration Navigator - ACO Team in Worcester, Massachusetts


Passionate about Helping People? Enjoy working with the Elderly? Looking for No Weekends/ No Holidays & Work/Life Balance?

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.

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. Apersonalized 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. The 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.

Brief summary of purpose:

The 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 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 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 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

  • Performs care coordination for members adhering to contact and duration frequencies documenting all activities in the TruCare system utilizing the appropriate assessment and/or note type following Clinical Integration Documentation Policy

  • Contacts members to resolve gaps in care including but not limited to: PCP assignment, PCP visits, preventative screenings, vaccination reminders, and other initiatives as assigned

  • Helps members obtain access to care including but not limited to working with providers to arrange medical and behavioral health appointments and following up with members afterwards to ensure they attended, if not determine barriers, and work to have members attend appointments as required

  • If working on the NaviCare Member Population: Facilitates transportation to medical, behavioral health, and social appointments by educating the member about the process to request transportation and/or working to assist the member to obtain such

  • If working on the ACO Member Population: Facilitates transportation to medical and behavioral health appointments by completing the MassHealth PT-1 process on behalf of the member/provider

  • Educates members and assists members to obtain community benefits including but not limited to food through the EBT system, fuel assistance and other community programs and services such as WIC

  • Screens members for social determinants and service needs and refers members to Clinical Team members and Partners for intervention based upon criteria and processes

  • If working on the ACO or Commercial Products and depending upon process: May contact maternity members after hospital discharge to facilitate delivery of items as part of the ‘Oh Baby’ program and works with Nurse Case Managers to coordinate after care needs

The Navigator refers to the Nurse Case Manager/PCP whenever clinical decision making is required.


Note: Job Responsibilities may vary depending upon the member’s Fallon Health Insurance Product

  • 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

  • Monitors the daily inpatient census and notifies all members of the care team during member care transitions including any discharge planning updates depending upon the product process

  • Works collaboratively with Embedded Navigators and Transition of Care Team RNs

  • Follows up with members following transition of care to ensure member attended follow up appointments, if they have any questions or concerns, and ensures all members of the Care Team are knowledgeable about the care transition and work collaboratively to ensure the member care plan meets needs

  • May conduct visits to hospital and Nursing Facilities during a Care Transition to participate in the discharge planning process (depending upon the product and circumstances)

  • May perform home visits with members (depending upon the product and circumstances).Visits may be by self, or with others on the Care Team

  • Responds promptly to member calls/questions and follows up per department processes at all times demonstrating exceptional customer service skills in a culturally sensitive way

  • Provides culturally appropriate care coordination i.e.: arranges for interpreters, provides communication documents in appropriate language, demonstrates culturally appropriate behavior when working with member/family

  • Develops and fosters relationships with members and providers/facilities and depending upon the product, to be the first point of contact for benefit related questions and is able to explain processes including but not limited to: coverage criteria, appeal rights and processes, authorization request process, formulary, and evidence of coverage details

  • Manages member panel in conjunction with other employed Clinical Integration Team members; depending on the Fallon Health product, withthe contracted Aging Service Access Point Geriatric Support Service Coordinator when applicable; and/or Community Partners; and contracted primary and specialty care providers – this includes conducting face to face or telephonic health risk assessments in aculturally sensitive way, completing care plans, and reviewing claims and other data which may indicate a need for Nurse Case Manager involvement and assessment

  • Assists the interdisciplinary team in identifying and addressing member barriers related to social determinants of health and care obtainment

  • Collaborates with the interdisciplinary team in identifying and addressing high risk members and transitions of care

  • 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 community senior/cultural centers and other external partners

  • Maintains up to date knowledge of Program/Product 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

  • Participates in member retention efforts by providing benefit advice and clarification upon knowledge of member dissatisfaction and potential to voluntarily leave the plan, as applicable

  • Collaborates with appropriate team members to ensure health education/disease management information is provided as identified

  • Educate members on preventative screenings and other health care procedures such as vaccines and screenings according to established protocols

  • 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

  • Follows through to ensure services/authorizations are in place as per the care plan, and if not, takes action for successful resolution

  • Facilitates member access to Program benefits, providing education about coverage criteria, explaining processes for member request determinations and helping members navigate the managed care system

  • 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

  • If working on the NaviCare product line, partners with the Long Term Care Team/Community Team when members are admitted to custodial care and/or discharged to the community to ensure admission and discharge planning needs for the member are met

  • May partner closely with the Advanced Practitioner staff to ensure facility and member needs are being met

  • 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

  • Reviews and validates data on Member Panel report generated from the TruCare ensuring member contacts, programs, services are accurate and up to date at all times for members on panel

  • Reviews claims and other reports monitoring for triggers and events that may warrant nurse case manager action (such as high dollar claims that may trigger a State assigned rating category change for NaviCare and ACO members) for members on panel

  • Maintains and updates TruCare and associated reports per Program processes for members on panel

  • Knowledge of and compliance with HEDIS and Medicare 5 Star measure processes performing member education


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

  • Understanding of hospitalization experiences and the impacts and needs after facility discharge required

  • Knowledgeable about medical terminology and basic understanding of common disease processes and conditions required

  • Knowledgeable about medical record documentation and able to recognize triggers requiring RN intervention required

  • Experience with telephonic interviewing skills and working with a diverse population, that may also be Non-English speaking required

  • Understanding of the impacts of social determinants of health required

  • Knowledgeable about software systems including but not limited to Microsoft Office Products – Excel, Outlook, and Word required

  • Experience conducting face to face member visits and interacting with providers and community partners preferred

  • Experience working in a community social service agency, skilled home health care agency, community agency such as adult foster care, group adult foster care, personal care management agency, independent living agency, State Agency such as the Department of Mental Health (DMH), Department of Developmental Services (DDS), Department of Children and Families (DCF), and/or the Department of Youth Services (DYS), or other agency servicing those in need preferred

  • Experience in a nursing facility or in a Massachusetts Aging Access Service Point Agency preferred

  • Experience working on a multi-disciplinary care team in a managed care organization preferred

AND IF Working with the ACO Member Population:

  • 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

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 about community resources available to assist the member population in the community and long term care settings and demonstrated willingness to seek resources and expand knowledge to assist the population

  • Willingness to learn insurance regulatory and accreditation requirements

  • Familiar with Excel spreadsheets to manage work and exposure and familiarity with pivot tables

  • Accurate and timely data entry

  • Effective care coordination skills and the ability to communicate, advocate, and follow through to ensure member needs are met

  • Knowledgeable regarding community resources

  • Ability to communicate effective to physician and other medical providers

  • Ability to effectively respond and adapt to changing business needs and be an innovative and creative problem solver


  • Demonstrates commitment to the Fallon Health Mission, Values, and Vision

  • Specific competencies essential to this position:

  • Problem Solving

  • Asks good questions

  • Critical thinking skills, looks beyond the obvious

  • Adaptability

  • Handles day to day work challenges confidently

  • Willing and able to adjust to multiple demands, shifting priorities, ambiguity, and rapid change

  • Demonstrates flexibility

  • Written Communication

  • Is able to write clearly and succinctly in a variety of communication settings and style

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 2 weeks ago (3/30/2021 8:40 AM)

Job ID 6288

# Positions 1

Category Administrative/Clerical