Fallon Health

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Care Coordinator-Case Management- Growing Health Insurance!

Care Coordinator-Case Management- Growing Health Insurance!

Job ID 
# Positions 
Posted Date 
Case Management

More information about this job


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 www.fallonhealth.org.


Position Overview: 

The Navigator helps the Nurse Case Manager, primary care provider and other providers know at all times what is occurring with the member and their status.  Responsibilities include:  conducting health risk assessments and identifying Fallon Health Care Management Programs the member may benefit from; educating Fallon Health members about their benefits; helping to ensure that physician office visits are scheduled and attended; placing referrals and following up to ensure services are in place as per the individual care plan and ensuring the member’s case is up to date. The Navigator works closely with the Nurse Case Manager.  The Navigator refers to the Nurse Case Manager/PCP whenever clinical decision making is required.  In order to effectively advocate for member needs, the Navigator may make in home visits with the Nurse Case Manager to fully understand a member’s care needs.


The Navigator seeks to establish a relationship with the member/caregiver(s) to better ensure ongoing service provision and care coordination, consistent with the member specific care plan.



  • Reviews member enrollment data, claims data, urgent and emergency room utilization, acute inpatient census, referrals from vendors, and other appropriate data prior to initiating a member contact.
  • Outreaches to all newly assigned members within designated time frame via the telephone.  Introduces self/role and ensures the member /caregiver is orientated to the Case Management Program and member benefits.
  • Responds to member /caregiver questions or concerns about their health/benefits
  • Makes in home/ office visits as need be to introduce self/role and ensure the member/caregiver is orientated to the Case Management Program and member benefits.
  • Coordinates member visits to the Primary Care Physician (PCP) and other clinicians as appropriate based upon clinical need and program guidelines.
  • Coordinates and ensures that the members of the Fallon Health Care Management Programs (Case Management, Disease Management, Behavioral Health Intensive Case Management and others) are involved with the member based upon individual need.
  • Coordinates and ensures appropriate providers are involved with the members based upon member need and PCP direction
  • Ensures the member’s individual plan of care is up to date in conjunction with plans developed by the PCP and Nurse Case Manager (NCM).
  • Ensures follows up activity with member after an emergent/urgent care need
  • Works with the emergent/urgent care provider to obtain documentation and ensures information is entered into the member’s case.
  • If any member assessment or reassessment is positive for new risk factors, the Navigator in conjunction with the NCM will update the care plan and initiate the development of a support system to avert further deterioration.  Such support system may include:
    • Arranging an urgent home  visit within 24 hours of the discovery to more fully assess the situation
    • Arranging an urgent office visit with the provision of transportation if needed.
  • Uses the appropriate Fallon Health application(s) to document all case activity and facilitate appropriate communication.
  • Identifies and shares best practices and innovative care management strategies with the team.
  • Resolves conflicts among participants in the care planning process.
  • Creates contingency plans for each step of the process to anticipate treatment and service complications, while ensuring that the member attains pre-determined outcomes.
  • Supports department colleagues, covering and assuming changes in assignment as assigned by Director/Designee
  • Strictly observes HIPAA regulations and the Fallon Health policies regarding confidentiality of member information.
  • Performs other responsibilities as assigned by the Manager/designee


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


License:  Current MA Drivers License     


Experience:  1-3 years job experience in a medical related field or with a healthcare payor company.  Experience in a healthcare payor company a plus.


Experience with telephonic and in person interviewing skills required


Experience working with a diverse population, newborn - geriatric.


Bilingual skills, fluency in Spanish preferred