Fallon Health Nurse Case Manager - Medicare & Community Care programs in Worcester, Massachusetts
The Medicare NCM position primarily works on transition of care assessments and ER follow up which is a heavy focus on care transitions. Someone with NCQA background is a huge plus!
About Fallon Health:
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, Fallon delivers equitable, high-quality coordinated care and is continually rated among the nation’s top health plans for member experience, service, and clinical quality. Today, guided by our mission of improving health and inspiring hope, we strive to be the leading provider of government-sponsored health insurance programs—including Medicare, Medicaid, and PACE (Program of All-Inclusive Care for the Elderly)— in the region. Learn more at fallonhealth.org or follow us on Facebook, Twitter, and LinkedIn.
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.
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
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
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
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
Performs other responsibilities as assigned by the Manager/designee
Supports department colleagues, covering and assuming changes in assignment as assigned by Manager/designee
Graduate from an accredited school of nursing mandatory and a Bachelors (or advanced) degree in nursing or a health care related field preferred.
License: Active, unrestricted license as a Registered Nurse in Massachusetts & current Driver’s license and a vehicle to be used for home visits
Certification : Certification in Case Management strongly desired
Other: Satisfactory Criminal Offender Record Information (CORI) results
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
Demonstrates commitment to the Fallon Health Mission, Values, and Vision
Specific competencies essential to this position:
Asks good questions
Critical thinking skills, looks beyond the obvious
Handles day to day work challenges confidently
Willing and able to adjust to multiple demands, shifting priorities, ambiguity, and rapid change
Is able to write clearly and succinctly in a variety of communication settings and styles
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.
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.
Posted Date 2 weeks ago (1/9/2023 12:32 PM)
Job ID 7147
# Positions 1