Fallon Health

  • RN Nurse Case Manager - Spanish speaking preferred to join our great team.

    Location US-MA-Worcester
    Posted Date 4 months ago(3/1/2018 8:32 AM)
    Job ID
    # Positions
  • Overview

    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.


    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.


    Brief Summary of purpose:

    The Nurse Case Manager Purpose is to:

    • Assess a member’s clinical/functional/behavioral health status
    • Develop an individualized care plan that supports the member in attaining and/or maintaining an optimal functional status
    • Coordinate a continuum of care consistent with the member’s health care needs and goals
    • Support members at time of care transition, participate in discharge planning, and work to ensure members are supported and have after discharge care plans adequate to meet needs
    • Provide care coordination and advocacy consistent with member specific care plan during care setting transitions
    • Responsible for the accuracy and timeliness of information captured in the Central Enrollee record per department policy and process
    • Ensure regulatory mandates are met including but not limited to Care Plans, Health Risk Assessment, and MDS HC assessments and submissions in the State Virtual Gateway
    • Strictly observes HIPAA regulations and the Fallon Health Policies regarding confidentiality of member information


    Member Assessment, Education, and Advocacy

    • Partners with NaviCare Outreach Team members to learn member unique needs and proactively partners to facilitate a smooth member onboarding experience 
    • Conducts in home face to face visits to assigned community dwelling members with member’s consent. Visits may be by self, or with others of the Primary Care Team 
    • Utilizing clinical judgment and nursing assessment; completes the Program Health Risk Assessment Tools and Minimum Data Set Home Care (MDS HC) Form within the first month of enrollment, and at intervals defined by the Program ensuring members are in the correct State defined rating category
    • Utilizes a variety of interviewing techniques, including motivational interviewing, and employs culturally sensitive strategies to engage and work with members
    • Assesses the Member’s knowledge about the management of current disease processes and medication regimen and teaches to increase Member/caregiver knowledge
    • Educates the member/caregivers to ensure enhancement of effective self-management skills
    • Advocates for members, and works to ensure the members participate in the development and approval of their care plans as appropriate in conjunction with the Navigator
    • Demonstrates an understanding of the NaviCare benefits and fosters collaborative working relationships with vendor and provider staff in order to advocate for members and ensure their care plans are supported by the vendor and providers to meet the member needs

    Care Coordination and Collaboration


    • 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 partners closely with Navigators to learn when members have a care transition, coordinates and communicates with Fallon Health Utilization Management staff on member needs, participates in discharge planning, and coordinates and communicates with facility case managers and others to ensure member needs and status is known and considered when after facility discharge plans are made 
    • Follows up with member telephonically or in person after facility discharge within designated time frames, performs care transition assessments and performs medication reconciliation and ensures services are in place and working effectively to meet member care plan needs 
    • Works collaboratively with Fallon Health Pharmacist, referring members in need of medication review based upon processes and program 
    • Providers culturally appropriate care coordination i.e. works with interpreters, provides communication approved documents in the appropriate language, demonstrates culturally appropriate behavior when working with member/family 
    • Develops and fosters relationship with members and providers – supports and encourages the Navigator as the first point of contact for non-clinical related questions/concerns 
    • 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 in a culturally sensitive way 
    • Manages members in the ‘AD/CMI’ and ‘Community Nursing Home’ levels in conjunction with the Navigators, Aging Service Access Point Geriatric Support Service Coordinator and contracted primary care provider
    • Collaborates with Navigators who manage the ‘Community Well’ members and performs clinical care transition assessments and other health risk assessments when members experience a care transition or other triggers that warrant an assessment of rating category
    • status – always involved with any ‘clinical’ issues and care coordination needs for this population
    • 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 Navigators to have the Navigators investigate and facilitate community options for the member
    • 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 supporting the Navigator and other members of the care team helping to resolve member dissatisfaction and potential to voluntarily leave the plan
    • Works collaboratively with care team members and work effectively in a team model approach to coordinate a continuum of care consistent with the Member’s health care goals and needs
    • Coordinates care between multiple medical and ICT members. The Nurse Case Manager is able to identify services, care delivery settings and recommends alternatives where appropriate
    • Develops member centered Care Plans and is responsible for Member Care Plan content appropriate to member needs
    • Monitors progression of member goals of care and provides consistent feedback to the ICT on progress. The Nurse Case Manager collaborates and works with all members of the ICT, including facility or community liaisons, when appropriate, to ensure effective outcomes of care plan to meet member care needs
    • Facilitates prompt and easy access to care appropriate to the disease or condition, in line with appropriate clinical guidelines
    • Actively involved with the member at times of care transition, including but not limited to planned and unplanned admissions, and works in conjunction with the member’s Navigator to ensure care plan communication between all providers and members of the ICT
    • Streamlines the focus of the Member’s healthcare needs utilizing the most optimal treatment approach, promoting timely provision of care, enhancing quality of life, and promoting cost-effectiveness of care
    • Identifies, aligns, and utilizes health plan and community resources
    • Identifies and shares best practices and innovative care management strategies with the team
    • The Nurse Case Manager goes to the member in the home to assess needs and monitor progress to goals as needed 

    Regulatory Requirements – Actions and Oversight


    • Completes Health Risk Assessments, Minimum Data Set Home Care (MDS HC) Assessments and Care Plans in the Centralized Enrollee Record and Virtual Gateway according to Regulatory Requirements and Program policies and processes  
    • Reviews and validates data on Member Panel report generated from TruCare on elements RN responsible for and takes action whenever data needs correcting 
    • Reviews claims and other reports monitoring for triggers and events that may warrant MDS HC submission to the State in order to facilitate appropriate State member rating category
    • Performs care transition activity per Program policies and processes
    • Knowledge of and compliance with HEDIS and Medicare 5 Star measure processes performing member education, outreach, and actions in conjunction with the Navigator team

    Provider Partnerships and Collaboration

    • Attends and contributes to scheduled and ad hoc provider Model of Care trainings/orientations with providers explaining nurse case manager role and NaviCare benefits and care coordination activities
    • Attends in person care plan meetings with providers and office staff and may lead care plan review with providers and care team at all times partnering with Navigator staff
    • Partners with interdepartmental teams within Fallon Health to ensure provider educational needs are met and provider/member satisfaction is maintained articulating issues for others to work to resolve problems
    • 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 works with the Navigator to ensure member and provider requests and needs are met
    • Demonstrates an understanding of the NaviCare benefits and fosters collaborative working relationships with vendor and provider staff in order to advocate for members and ensure their care plans are supported by the vendor and providers to meet the member needs


    Education: Graduate from an accredited school of nursing mandatory and a Bachelors (or advanced) degree in nursing or a health care related field preferred.

    License: Active, unrestricted license as a Registered Nurse in Massachusetts; current Driver’s license and a vehicle to be used for home visits

    Certification: Certification in Case Management strongly desired

    Other: Satisfactory Criminal Offender Record Information (CORI) results



    A minimum of one year of clinical experience as a Registered Nurse managing chronically ill/geriatric patients or related experience working in the NaviCare Program with the demonstrated ability to learn and apply nursing knowledge and skills with the guidance of a clinical mentor/preceptor. Working with Non-English speaking elder populations preferred.


    Demonstrates proficiency including but not limited to:

    • Physician and other health care provider interaction and other communication including but not limited to face to face communication
    • Software systems including but not limited to Microsoft Office Products – Excel, Outlook, and Word
    • 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
    • Ability to organize schedule, and prioritize to meet the requirements of the position.
    • Case management skills and care coordination skills

    • 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 geriatric medical concerns, issues, and needs
    • Ability to assess a member’s activities of daily function and independent activities of daily function and the ability to develop and implement a care plan that meets the member’s need
    • Knowledgeable about community resources, levels of care, criteria for levels of care and the ability to appropriate develop and implement a care plan following regulatory guidelines and level of care criteria
    • Ability to effectively respond and adapt to changing business needs and be an innovative and creative problem solver
    • Critical thinking skills for independent problem solving


    Sorry the Share function is not working properly at this moment. Please refresh the page and try again later.
    Share on your newsfeed