Fallon Health RN Case Manager ACO - New Role - OB GYN High Risk Experience needed - Growing Healthcare Organization 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.
The Nurse Case Manager is focused on care coordination and improving quality of care and access to services for Fallon members. The Nurse Case Manager will support the Clinical Integration Team in a role that routinely completes in-home/facility face to face and telephonic assissments/visits with members and/or providers. Responsibilities include: telephonically assessing a Members clinical/functional status to identify ongoing special conditions and providing education. Develops and implements an individualized, coordinated care plan in collaboration with the member and Primary Care Provider and/or specialist and other community partners to ensure quality outcomes in a cost effective way. Communicates with member/family/caregiver(s) in accordance with frequency of Case Management contact guidelines. Works collaboratively with other members of the Clinical Integration Team.
Looking for a candidate with OB-GYN and High Risk Experience.
Member Assessment, Education, and Advocacy.
Completes telephonic assessmentsutilizing a variety of interviewing techniques, including motivational interviewing, and employs
culturally sensitive strategies to assess a Members clinical/functional status to identify ongoing special conditions
Develops and implements an individualized, coordinated care plan, in collaboration with the member and Primary Care Provider and/or specialist and other community partners
Performs medication reconciliations
Performs Care Transitions Assessments – per Program Processes
Utilizing clinical judgment and nursing assessment skills, completes the Program Assessment Tools.
Maintains up to date knowledge of Program 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 members benefit package
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
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-effective care
Actively participates in internal clinical rounds
Regulatory Requirements – Actions and Oversight
Completes Program Assessments, Transition of Care Assessments, and Care Plans in the Centralized Enrollee Record and Virtual Gateway according to Regulatory Requirements and Program policies and processes
Knowledge of and compliance with NCQA, HEDIS and Medicare 5 Star measure processes, performing member education, outreach, and actions in conjunction with the Navigator
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
L icense: 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
Job ID 5599
# Positions 1