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 the only health plan in Massachusetts to have been awarded “Excellent” Accreditation by the National Committee for Quality Assurance for its HMO, Medicare Advantage and Medicaid products. For more information, visit www.fallonhealth.org.
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 NaviCare Navigator purpose is to:
Member Education, Advocacy, and Care Coordination
Manages members in the ‘Community Well’ Program with the contracted Aging Service Access Point Geriatric Support Service Coordinator and contracted primary care provider – this includes conducting face to face or telephonic health risk assessments in a culturally sensitive way, completing care plans, and reviewing claims and other data which may indicate a need for Nurse Case Manager involvement and assessment
Serves as an advocate for members to ensure they receive NaviCare benefits as appropriate and if member needs are identified but not covered by NaviCare, works with community agencies to facilitate access to programs such as community transportation, food programs, and other services available through senior centers and other community programs
Maintains up to date knowledge of Program benefits, Evidence of Coverage details, and department policies and processes and follows policies and processes as outlined
Provider Partnerships and Collaboration
Access to Care
Facilitates member access to Program benefits, providing education about coverage criteria, explaining processes for member request determinations and helping members navigate the managed care system
Care Team Communication
Regulatory Requirements – Actions and Oversight
College degree (BA/BS in Health Services or Social Work) preferred
Current MA Driver's License
2+ years job experience in a medical related field or community social service agency required.
Experience working face to face with elders required. Working with Non-English speaking elder populations preferred.
Experience in a healthcare managed care company, nursing facility, or in a Massachusetts Aging Access Service Point Agency or State Social Service Agency a plus.
Demonstrated proficiency including but not limited to: