Fallon Health

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Clinical Care Coordinator / Navigator Fallon Health

Clinical Care Coordinator / Navigator Fallon Health

Job ID 
5009
# Positions 
1
Location 
US-MA-Holyoke
Posted Date 
12/5/2017
Category 
Care Coordination

More information about this job

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 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.

 

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. 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:

  • Perform tasks and actions to ensure all CMS and State member related regulatory mandates are met including but not limited to welcome calls, care plans, health risk assessments for the ‘Community Well’ member population, and member service plans according to Program Policy and Process
  • Manage a member panel in conjunction with other employed NaviCare Clinical Team members (members other than those in the State assigned ‘Community Well’ Program) in a culturally sensitive way
  • Manage 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
  • Educate and assist members and/or personal authorized representatives (PRAs) on matters associated with NaviCare insurance coverage and benefits performing a member advocacy and education role including but not limited to member rights
  • Establish positive relationships with members/caregivers, community providers, and others involved in member care
  • Proactively intervene and work to help retain members on the plan when dissatisfaction or other issues may result in a member voluntarily leaving the plan
  • Be the central communicator and care coordinator to all members of the interdisciplinary care team and keep care team members abreast on member status during their membership in the plan and also at time of care transition to ensure care team members know of the member care transition so they are able to proactively participate in member discharge planning needs
  • Educate members on their unique care plan and obtains their approval 
  • Educate members on preventative screenings and other health care procedures such as vaccines, screenings according to established protocols and program process
  • Generate requests and authorizations for Medicaid covered services per the member care plan ensuring all services requiring authorization have accurate and timely authorizations in place in the Fallon Health system with accuracy and timeliness per program process
  • Educate providers, contracted vendors, Aging Service Access Point staff, and others about the NaviCare Program and benefits
  • Provide care coordination consistent with member specific care plan, ensuring the services that are on the care plan are implemented 
  • Obtain medical records and other required documents from the health care providers and ensures uploading into the Central Enrollee Record
  •  May be embedded in provider offices/sites/facilities at all times representing NaviCare in a positive collaborative manner
  •  May lead member case review with providers and other members of the care team

Responsibilities

 

Member Education, Advocacy, and Care Coordination

  • Partners with NaviCare Outreach Team members to learn member unique needs and proactively partners to facilitate a smooth member onboarding experience
  • Conducts in home visits to members with member’s consent in a culturally sensitive way. Visits may be by self, or with others on the Care Team
  • Monitors the daily in patient census and notifies all members of the care team when members have a care transition and ‘where’ they are for discharge planning and communication purposes
  • Follows up with members following transition of care to ensure member attended follow up appointments, if they have any questions etc. and ensure all members of the Care Team are knowledgeable about the care transition and work collaboratively to ensure the member care plan meets needs
  • 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
  • Develops and fosters relationships with members and providers/facilities to be the first point of contact for NaviCare insurance and benefit related questions and is able to explain processes including but not limited to: coverage criteria, appeal rights and processes, authorization request process, formulary, and evidence of coverage details
  • Performs home visits with members, responds promptly to member calls/questions and follows up per department processes at all times demonstrating exceptional customer service skills
  • Manages a member panel in conjunction with other employed NaviCare Clinical Team members (members other than those in the State assigned ‘Community Well’ Program) in a culturally sensitive way
  • 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

  • Provides education about NaviCare Benefits and Evidence of Coverage processes
  • Participates in member retention efforts by providing benefit advice and clarification upon knowledge of member dissatisfaction and potential to voluntarily leave the plan

Provider Partnerships and Collaboration

  • Attends and contributes to scheduled and ad hoc provider Model of Care trainings/orientations with providers explaining Navigator role and NaviCare benefits
  • Attends in person care plan meetings with providers and office staff and leads care plan review with providers and care team
  • Partners with interdepartmental teams within Fallon Health to ensure provider educational needs are met and provider/member satisfaction is maintained, working to resolve issues expressed
  • Embeds at provider/facility sites as assigned and represents Fallon Health and the NaviCare Program in a positive collaborative manner
  • Demonstrates positive customer service actions and takes responsibility to ensure member and provider requests and needs are met
  • Ensures accurate membership reports based upon provider/facility, distributes reports ensuring accuracy of data, updates and maintains provider sheets as applicable

 

Access to Care

  • Generates requests and authorizations for Medicaid covered services per the member care plan ensuring all services requiring authorization have accurate and timely authorizations in place in the Fallon Health system with accuracy and timeliness per program process
  • Educates members and providers on authorization processes, educates about authorization review outcomes, works to resolve authorization related issues and concerns
  • Follows through to ensure services/authorizations are in place as per the care plan, and if not, takes action for successful resolution
  • 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

  • Follows established transition of care workflow including but not limited to: communicating to all members of the Primary Care Team when a care transition occurs and documents per workflow
  • Works collaboratively and ensures communication with members of the Primary Care Team including but not limited to, medical providers, and member/PRAs to ensure member care plan supports their needs
  • Partners with the NaviCare Long Term Care Team/Community Team when members are admitted to custodial care and/or discharged to the community to ensure admission and discharge planning needs for the member are met

Regulatory Requirements – Actions and Oversight

  • Completes timely Health Risk Assessments, Service Plans, and Care Plans in the Centralized Enrollee Record according to Regulatory Requirements and Program policies and processes
  • 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 member on panel
  • Reviews claims and other reports monitoring for triggers and events that may warrant nurse case manager action (such as high dollar claims that may trigger a State assigned rating category change) for members on panel
  • Maintains and updates the TruCare Centralized Enrollee Record system 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, outreach, and actions
  • Obtains medical records and other required documents from the health care providers and ensures uploading into the Central Enrollee Record

Qualifications

Education:

 

College degree (BA/BS in Health Services or Social Work) preferred

 

License:

 

Current MA Driver's License

 

Experience:

 

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:

  • Software systems including but not limited to Microsoft Office Products – Excel, Outlook, and Word
  • Manipulation of Excel spreadsheets to manage work and exposure and familiarity with pivot tables
  • Physician and other health care provider interaction and other communication including but not limited to face to face communication with physicians and health care providers
  • Independent learning skills and success with various learning methodologies including but not limited to: self-study, mentoring, classroom, and group education
  • Exceptional customer service skills and willingness to assist ensuring timely resolution
  • Working 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
  • Knowledgeable about community resources available to assist the elder population in the community and long term care settings and demonstrated willingness to seek resources and expand knowledge to assist the population
  • Knowledgeable about MassHealth qualifications and requirements
  • Knowledgeable about medical terminology and basic understanding of common disease processes and conditions in the elder population
  • Knowledgeable about medical record documentation
  • Critical thinking skills for independent problem solving

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