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Fallon Health Social Worker -Clinical Integration Medicare - Make the difference! REMOTE in Worcester, Massachusetts

Overview

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 Social Care Manager (SCM) provides coordination and advocacy services to members and assesses a member’s behavioral health and social care needs with a keen focus on social determinants of health and develops and implements plans to mitigate, minimize, and resolve related impacts utilizing resources from the community utilizing federal, state, and local programs/benefits with the member consent and agreement/active participation.

The SCM assists members and/or family/PRAs in utilizing Fallon Health benefits additionally to address these needs often times partnering and working with contracted providers and Fallon Health Care Team members involved in member care coordination.

Key actions and responsibility of the Social Care Manager includes but is not limited to:

  • Screening for various financial and community support needs

  • Assisting with applications and conference calls with member and community agencies advocating for needs

  • Screening for Medicaid and waiver eligibility, assisting with applications

  • Housing applications for subsidized housing (section 8, AHVP, MRVP, CHAMP, federal, project based programs) meeting with housing authorities and housing attorneys to advocate for members to prevent eviction, referral to Tenancy Preservation Programs

  • Screening for possible enrollment with SCO and PACE and referring

  • Work with community partners including but not limited to: SHINE, SNAP, EAEDC/TAFDC, food pantries, Meals on Wheels, transport

  • Assist with BH services, following up with providers as needed providing brief crisis intervention or de-escalation to members as needed

  • Coordination with Probation officers ensuring appropriate release of medical information forms are on file and coordination with medical and behavioral health providers and community resources

  • Refer and coordinate with agencies such as ILCs, ASAPs, MRC, (HCAP, Vocational, SHIP, etc.), MA Commission for the Blind and MA Commission for deaf and hard of hearing to assist getting services

  • Outreach to Social Security, Dept. of Treasury, banking institutions

  • RX Assistance Programs (i.e. RX Advantage, Extra Help, MCPSS outreach program, manufacturer programs) obtaining samples for members from providers

  • Community legal aid assisting with referral, coordination, and advocacy

  • Outreach to PCPs for concerns when RNs/Navigators are not involved

  • Childcare, vocational resources, work with assistive technology programs

  • Holiday assistance programs and other work with community resources

  • Assist with clothing and diaper donations

Responsibilities

Member Education, Advocacy, and Care Coordination

  • Is a subject matter expert in federal/state/community entitlement and other benefit programs keeping up to date with current guidelines program availability, access details and other pertinent details associated with eligibility and obtainment

  • Assesses member’s and their needs in common social determinants of health areas including but not limited to: housing, finances, transportation, food insecurities, housing insecurities developing a collaborative plan with the member to obtain assistance to meet needs

  • 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, working 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

  • Assists the Care Team members in identifying and addressing member barriers related to social determinants of health and care obtainment

  • Assists members/caregivers to apply for community services and funding arrangements as necessary

  • Assists members in establishing or reinforcing a social support network, thereby reducing their dependence on the medical system

  • Follows up with members following actions, actively participating with the member in conference calls and activities with community resources when members are not able to advocate for themselves

  • May conduct member face to face visits to assess needs and the environment and educate on resources and next steps as required. 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 often times utilizing translators when working with documents that are only available to the public in English

  • Develops and fosters relationships with members and providers/facilities

  • 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 working in partnership and collaboration to meet member needs

  • Educate members on preventative screenings and other health care procedures such as vaccines and screenings according to established protocols entering information into the documentation system as required

  • Resolves conflicts among participants in the care planning process

  • Issues letters per departmental policy and procedure

Provider/Community Resource Partnerships and Collaboration

  • May attend in person meetings with member/partners/providers and be an active participant in care plan review and member scenario presentations

  • Demonstrates positive customer service actions and takes responsibility to ensure member and provider requests and needs are met

Additional Job Related Responsibilities

  • 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

  • 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

  • Utilize reports identifying gaps in care and follow up per program protocol

  • Participates actively with manager during monthly supervision meetings

  • Performs other responsibilities as assigned by the Manager/designee

  • Supports department colleagues, covering and assuming changes in assignment as assigned by Manager/designee

  • May mentor and train staff on processes associated with job function and role

Qualifications

Education:

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

License: Active, unrestricted license as an LCSW and/or LMHC or license-eligible a plus

Certification : Certification in Case Management preferred

Other: Reliable transportation and Satisfactory Criminal Offender Record Information (CORI) results

Experience:

  • Two plus years of experience working with the following populations and situations including but not limited to: geriatrics, substance use disorders, Serious/persistent mental illness, homeless required

  • Experience working in a healthcare setting as a member of a professional clinical team required

  • Experience working with state agencies, community social service agencies and non-profits required

  • Experience and comfort conducting face-to-face visits with membership in the community and in their homes required

  • Experience working with court systems, State agencies such as DCF, DMH, DYS preferred

  • Background working with all age groups preferred

  • Previous experience working at an insurer preferred

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.

JT18

Location US-MA-Worcester

Posted Date 1 week ago (11/24/2021 1:26 PM)

Job ID 6587

# Positions 1

Category Case Management

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