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Fallon Health Social Work Care Manager, Mass Health ACO Program - Remote 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.

Brief summary of purpose :

  • The ACO Social Work Care Manager (SWCM) works very closely with ACO Partners, Community Partners, and community based groups to address service gaps and serves as a liaison to social and health resources on behalf of Fallon Health and the Fallon Health ACO Model of Care.

  • The SWCM will collaborate and coordinate with State Agencies, DMH, DDS, DYS, DCF to ensure members care is efficient and coordinated.

  • The SWCM provides social service coordination services to ACO members as referred assessing member needs, services and resources to address social, health, or economic needs and facilitates referrals and collaboration with ACO Provider Care Teams and BH Partners in the community.

  • The SWCM assists the member and or family to provide care utilizing FH benefits and/or community resources developing a plan to coordinate a continuum of care consistent with the members’ health care needs and/or goals.

  • The SWCM uses their knowledge of benefit plan design, eligibility and/or financing alternatives available within the community to provide options that meet member’s needs.

  • The SWCM identifies services, care delivery settings, and funding arrangements that meet the needs of the members. He/She recommends alternatives where appropriate. The SWCM monitors services and provides consistent feedback to the team on progress.

  • The SWCM collaborates and works with members of the Care Team both at Fallon Health and at the ACO Partners during time of member transition of care.


ACO Member 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 Care Coordinator 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

  • Actively participates in internal clinical rounds and huddles

  • Works with members of the Utilization Management Department assisting with difficult or complex care delivery or discharge planning needs for ACO members

  • Actively participate with Beacon team and collaborate on high risk members to decrease utilization

  • May collaborate with ACO staff on site to facilitate communication between Fallon and ACO teams

  • Assists with care coordination with ACO Partners to engage in Interdisciplinary team meetings

  • Works with Nurse Case Managers and Navigators to coordinate a continuum of care for ACO members consistent with the member’s health care goals and needs

  • Maintains an ongoing awareness of clinical, social, and financial resources available in the community as well as State/Federal and National Resources and connects and advocates for members as appropriate

  • Performs other responsibilities as assigned by a member of the Clinical Integration Leadership Team

  • Participates in monthly supervision and one on one meetings with the manager



Master’s degree from an accredited school of social work, mental health counseling, psychology, or human services required.


Active, unrestricted license as a Licensed Independent Clinical Social Worker or Licensed Mental Health Counselor in Massachusetts; Reliable transportation required.

Certification :

Certification in Case Management strongly desired


  • Four years of experience working with the following: the chronically ill, SPMI, and substance use populations required.

  • Experience and comfort conducting face-to-face visits with members in the community and in home settings required.

  • Experience working in a multi-disciplinary care team required.

  • Experience working and providing collaborative care management interventions with various State Agencies such as DMH, DDS, DCF, DYS required.

  • Experience working with provider groups such as medical and/or mental health providers required.

  • Background working with all age groups preferred.

  • Previous experience working at a Managed Care Organization preferred.

Resources used in performing role :

Microsoft products (Word, Excel, Visio, PowerPoint, Outlook); reporting software such as Business Objects; Boxer Application; CaseNET TruCare System; QNXT System, Provider EMRs as applicable


Satisfactory Criminal Offender Record Information (CORI) results.


Location US-MA-Worcester

Posted Date 2 days ago (12/1/2020 11:55 AM)

Job ID 6131

# Positions 1

Category Case Management