About us:

Fallon Health is a company that cares. We prioritize our members—always—making sure they get the care they need and deserve. Founded in 1977 in Worcester, Massachusetts, Fallon Health delivers equitable, high-quality, coordinated care and is continually rated among the nation’s top health plans for member experience, service, and clinical quality. We believe our individual differences, life experiences, knowledge, self-expression, and unique capabilities allow us to better serve our members. We embrace and encourage differences in age, race, ethnicity, gender identity and expression, physical and mental ability, sexual orientation, socio-economic status, and other characteristics that make people unique. Today, guided by our mission of improving health and inspiring hope, we strive to be the leading provider of government-sponsored health insurance programs—including Medicare, Medicaid, and PACE (Program of All-Inclusive Care for the Elderly)— in the region. Learn more at fallonhealth.org or follow us on Facebook, Twitter and LinkedIn.

Brief summary of purpose: 

The ACO Navigator is an integral part on an interdisciplinary team focused on care coordination, care management and improving access to and quality of care for Fallon ACO members.

The ACO Navigator partners with the ACO Care Team staff and other providers to communicate at all times what is occurring with the member and their status.  The Navigator seeks to establish telephonic and face to face (depending upon product and circumstance) relationships with the member/caregiver(s) and provider partners to better ensure ongoing service provision and care coordination, consistent with the member specific care plan.

In order to effectively advocate for member needs, the Navigator may make in home or facility with or without other Care Team members to fully understand a member’s care needs.   

Member Education, Advocacy, and Care Coordination

• Utilizes an ACD line to support department and incoming/outgoing calls with the goal of first call resolution with each interaction
• Performs 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/care needs screening for the member population, and member service plans according to Program Policy and Process for the particular member product
• Works collaboratively with Embedded and Partner Staff
• Follows up with members following transition of care to ensure member attended follow up appointments, if they have any questions or concerns, and ensures all members of the Care Team are knowledgeable about the care transition and work collaboratively to ensure the member care plan meets needs
• Responds promptly to member calls/questions and follows up per department processes at all times demonstrating exceptional customer service skills in a culturally sensitive way
• 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 and depending upon the product, to be the first point of contact for 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
• Assists the interdisciplinary team in identifying and addressing member barriers related to social determinants of health and care obtainment
• Collaborates with the interdisciplinary team in identifying and addressing high risk members and transitions of care
• Serves as an advocate for members to ensure they receive Fallon Health benefits as appropriate and if member needs are identified but not covered by Fallon Health, works with community agencies to facilitate access to programs such as community transportation, food programs, and other services available through community senior/cultural centers and other external partners
• Maintains up to date knowledge of Program/Product benefits, Member Handbook details, and department policies and processes and follows policies and processes as outlined to be able to provide education to members and providers; performing a member advocacy and education role including but not limited to member rights

Provider Partnerships and Collaboration

• Demonstrates positive customer service actions and takes responsibility to ensure member and provider requests and needs are met

Access to Care

• Educates members and providers on authorization processes, educates about authorization review outcomes, works to resolve authorization related issues and concerns depending upon the member product and workflows
• 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

• Works collaboratively and ensures communication with members of the Care Team including but not limited to, medical providers, and member/PRAs

Regulatory Requirements – Actions and Oversight 

• Completes timely Care Needs Screening in the TruCare system (care management platform) 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 members 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 NaviCare and ACO members) for members on panel

Other

• Performs other responsibilities as assigned by the Manager/designee
• Supports department colleagues, covering and assuming changes in assignment as assigned by Manager/designee
• May mentor and train staff on processes associated with job function and role. 

Education: 

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

License/Certifications: 

License:  Current MA Driver’s License and reliable transportation   

Certification:  None   

Experience: 

• 2+ years of experience working with people up to age 65 with a focus on working with people that are on MassHealth coverage and may be encountering social, economic, and/or multi complex medical and or behavioral health conditions required
• IF focused to work with the pregnant member population, 2+ years of experience working with pregnant females during the prenatal, delivery, and postpartum time working in conjunction with RNs coordinating care required
• Understanding of hospitalization experiences and the impacts and needs after facility discharge required
• Knowledgeable about medical terminology and basic understanding of common disease processes and conditions required
• Knowledgeable about medical record documentation and able to recognize triggers requiring RN intervention required
• Experience with telephonic interviewing skills and working with a diverse population, which may also be non-English speaking required
• Understanding of the impacts of social determinants of health required
• Knowledgeable about software systems including but not limited to Microsoft Office Products – Excel, Outlook, and Word required
• Effective telephonic interviewing skills and the demonstrated ability to coordinate MassHealth benefits such as transportation through the State PT-1 process preferred
• Experience conducting face to face member visits and interacting with providers and community partners preferred
• Experience working in a community social service agency, skilled home health care agency, community agency such as adult foster care, group adult foster care, personal care management agency, independent living agency, State Agency such as the Department of Mental Health (DMH), Department of Developmental Services (DDS), Department of Children and Families (DCF), and/or the Department of Youth Services (DYS), or other agency servicing those in need preferred
• Experience working on a multi-disciplinary care team in a managed care organization preferred

COVID-19 Vaccination:

With the end of the Global Coronavirus COVID-19 Pandemic, Fallon Health no longer requires all employees to be vaccinated against COVID-19 except for employees who are in jobs that under state and federal laws, regulations and policies are required to be vaccinated and/or they are in Member/participant facing positions.

Fallon Health provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.