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.
The NaviCare Navigator purpose is to:
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
Member Education, Advocacy, and Care Coordination
Provider Partnerships and Collaboration
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
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.
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: