Fallon Massachusetts Jobs

Job Information

Fallon Health RN Nurse Case Manager - Looking for Spanish Speaking Nurse to join our great team!! in Worcester, Massachusetts


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.

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 Nurse Case Manager Purpose is to:

  • 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

  • Support members at time of care transition, advocating at time of discharge and facilitation with the primary care team to ensure the care plan is effective to meet care needs teaching about disease process, medications, and other strategies as required

  • Collaborating with all members of the primary care team, the member, designated care givers, and others involved in the member care

  • Assess members for long term services and supports and apply coverage criteria to determine level of care and number of hours for programs such as personal care attendant, group adult foster care, adult foster care, short term custodial care, and other long term services in supports in collaboration with the Aging Service Access Point staff, long term care facilities, and members of the primary care team

  • Communicate with primary care providers and other medical and service providers about a member’s clinical status and needs

  • Document all actions/assessments/care coordination in the documentation system according to Program Policy and Process

  • Complete regulatory mandates per requirements including but not limited to Health Risk Assessments, Care Plans, MDS HC assessments and submissions in the State Virtual Gateway

  • Strictly observes HIPAA regulations and the Fallon Health Policies regarding confidentiality of member information


Member Assessment, Education, and Advocacy

  • In collaboration with the NaviCare Outreach Team, works to facilitate a smooth new member onboarding experience and provides excellent customer service at all times

  • Conducts in home face to face visits to assigned community dwelling members with member’s consent. Visits may be by self, or with others of the Primary Care Team

  • Utilizing clinical judgment and nursing assessment skills, completes the Program Health Risk Assessment Tools and Minimum Data Set Home Care (MDS HC) Form within the first month of enrollment, and at intervals defined by the Program ensuring members are in the correct State defined rating categoryDemonstrates knowledge of the NaviCare benefits and applies coverage criteria, payment policy, and MassHealth guidelines when developing and implementing member care plans teaching members and other members of the primary care team about benefits, qualifications, and coverage criteria

  • Utilizes a variety of interviewing techniques, including motivational interviewing, and employs culturally sensitive strategies to engage and work with members

  • Assesses the Member’s knowledge about the management of current disease processes and medication regimen and provides teaching to increase Member/caregiver knowledge

  • Educates the member/caregivers to ensure enhancement of effective self-management skills and educates and provides caregiver education and support

  • Assesses members at time of care transition and completes assessments

  • Ensures members/PRAs participate in the development and approval of their care plans in conjunction with the interdisciplinary primary care team

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

  • Manages complex community members in the ‘AD/CMI’ and ‘Nursing Home Certifiable’ rating categories in conjunction with the Navigators, Behavioral Health Case Managers, Aging Service Access Point Geriatric Support Service Coordinators, contracted Primary Care Providers and others involved/authorized in the member’s care

  • With member/authorized representative(s) collaboration develops member centered care plans by identifying member care needs while completing program assessments and developing care plans 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

Care Transitions – per Program Processes :

  • Works closely with the Navigator, who closely monitors the daily inpatient census, to learn when the member has a care transition

  • Communicates and coordinates member care needs and discharge plans with Fallon Health Utilization Management staff

  • Participates in discharge planning meeting at the facility to ensure member care needs are met before and after discharge

  • Follows up with member/PRA telephonically or in person after discharge to perform Transition of Care assessment, medication reconciliation, and ensure services are in place as care planned within designated time frames

  • 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-effectiveness of care

  • Collaborates with Navigators who manage the ‘Community Well’ members and performs clinical care transition assessments and other health risk assessments when members experience a care transition or other triggers that warrant an assessment of rating category status – always involved with any ‘clinical’ issues and care coordination needs for this population

  • Reviews and validates data on Member Panel report generated from TruCare and takes action to ensure accurate data

Regulatory Requirements – Actions and Oversight

  • Completes Health Risk Assessments, Minimum Data Set Home Care (MDS HC) 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

  • Reviews member claims and available reports to determine if a change in status may warrant MDS HC submission to the Virtual Gateway facilitating the appropriate State rating category

  • Knowledge of and compliance with HEDIS and Medicare 5 Star measure processes, performing member education,outreach, and actions in conjunction with the Navigator

Provider Partnerships – Collaboration – Work with Fallon Health Teams

  • Demonstrates knowledge of the NaviCare benefits and coverage criteria and fosters collaborative working relationships with vendor and provider staff

  • Demonstrates positive customer service actions and works with the Navigators and Behavioral Health Case Managers to ensure member and provider requests and needs are met

  • When invited by Outreach/Provider Relations/NaviCare Clinical Leadership Team attends and contributes Model of Care trainings/orientations with providers and/or vendors explaining the various roles of the clinical team in coordination of member’s care

  • Performs and may lead face to face or in-person member care plan review with providers including but not limited to Primary Care Providers, Aging Service Access Point Providers, Long Term Services and Support Providers, Behavioral Health Providers, Long Term Care Facility Providers, and/or any other Provider/Member/Authorized Representatives to ensure effective communication and collaboration between all involved

  • May be embedded in certain Provider Facilities and works collaboratively with Provider Facility staff maintaining professional communications and educates about NaviCare benefits, coverage criteria, enrollment requirements and other Program related details

  • Partners with interdepartmental teams (including but not limited to: Utilization Management, Appeals and Grievance, NaviCare Operations, Provider Relations, Pharmacy, Behavioral Health Leadership) within Fallon Health to ensure provider/member satisfaction is maintained while articulating issues to help to facilitate problem/issue resolution


Education: 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

A minimum of two years of clinical experience as a Registered Nurse managing chronically ill/geriatric patients or experience in a coordinated care program servicing the needs of elders preferred. Working with Non-English speaking

elder populations preferred.

Demonstrates proficiency including but not limited to:

  • 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

  • Work 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

  • Ability to organize, schedule, and prioritize to meet the requirements of the position

  • Effective case management and care coordination skills

  • Knowledge about community resources, 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

  • Exceptional customer service skills and willingness to assist ensuring timely resolution

  • Knowledge about geriatric medical concerns, issues, and needs

  • Physician and other health care provider interaction and other communication including but not limited to face to face communication

  • 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

  • Software systems including but not limited to Microsoft Office Products – Excel, Outlook, and Word

Job ID 5549

# Positions 1

Category Nursing