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 Clinical Integration Program Support Coordinator’s function and role assists the Clinical Integration staff in providing care management services to Fallon Health member populations.    The Program Support Coordinator performs valuable ‘back office’ functions that support and enable the various roles in the department to outreach and work with member populations.   

This role requires an in office presence (full days) at 1 Mercantile St on a regular basis (about 2 days or more) as determined by Supervisor.

 Duties include but are not limited to: 

• Receives incoming member completed health risk assessment tools including but not limited to ACO member Care Needs Screenings and keypunching details in the documentation system, and assigns members for outreach based upon member responses to trigger questions
• Receives incoming member referrals and utilizing the documentation system to assign member for Care Team outreach in the various available Clinical Integration Team Programs
• Receives NaviCare member enrollment notifications (enrollment/disenrollment) from the Operations Team and communicates this information to the clinical team for outreach utilizing established processes.
• Creates NaviCare member authorizations in the TruCare system for member admissions to long term care facilities for short term and custodial care
• Manages medical records request
• Processes all incoming/outgoing member mail generated by the Care Team staff and ACO partners with accuracy
• Manages incoming faxes and member specific data, routing to the appropriate Care Team member
• Produces, manipulates, and maintains various reports utilized by the Clinical Integration Teams to manage and facilitate member care
• Produces, manipulates, and sends monthly ASAP rosters with NaviCare membership ensuring accuracy in data regarding member status
• Supports the Clinical Integration Team with data reconciliation efforts including but not limited to entering data into the QXNT and TruCare systems to ensure accuracy in reporting
• Manages incoming requests from vendors/ASAPs/providers for access to the TruCare Documentation system performing reconciliations with vendors/ASAPs/providers
• Manages deactivation for vendor/ASAP/provider TruCare users when access no longer required in conjunction with I.T. department
• Manages deactivation for ACO TruCare users when access no longer required in conjunction with I.T. department
• Generates and updates rosters of vendor/ASAP/provider TruCare users
• Receives and processes incoming vendor invoices ensuring members receiving services at such point in time have active membership
• Provides back up to Team members and is fully trained in all functions completed by the Clinical Integration Support Team
• Demonstrates a detailed working knowledge of the TruCare documentation system as well as Fallon Health’s core system QNXT
• In coordination with the Administrative Assistant, manages the supplies inventory for paper, and copier supplies, etc.
• Manages the communication of ACO care plans to the members and their PCPs.
• Provides additional support to the ACO Community partner (CP) and Flex Program Coordinator as needed and directed by Supervisor/Manager

Primary Job Responsibilities: 

New Member Processing and Referral  Functions: 

• Receives incoming member completed health risk assessment tools including but not limited to ACO member Care Needs Screenings, keypunching details in the documentation system and assigning members for outreach to the ACO team based upon member responses to trigger questions
• Receives incoming member referrals and utilizing the documentation system to assign member for Care Team outreach in the various available Clinical Integration Team Programs
• Receives incoming new NaviCare members and completes the new enrollee documentation system workflows and assignment to Care Team members for outreach utilizing the New Enrollee process.
• Receives NaviCare member enrollment notifications (enrollment/disenrollment) from the Operations Team and communicates this information to the clinical team utilizing established processes.
• Maintains accurate Team member assignment logic system(s) keeping abreast of staff arrival/departure/team changes to ensure assignment logic is current escalating needs for change to assignment logic ongoing
• Creates NaviCare new member detail report for current and future month creating pivot tables demonstrating volume of new NaviCare members to nurse case manager and navigator staff each business day and reconciles to ensure accuracy and timeliness of new member processing 

Member Related Supportive Functions (administrative):

• Creates NaviCare member authorizations in the TruCare system for member admissions to long term care facilities for short term and custodial care
• Processes all incoming/outgoing member mail (letters and other approved materials) generated by the Care Teams staff and ACO partners with accuracy
• Manages incoming faxes and member specific data, routing to the appropriate Care Team member
• Manages the Clinical Integration non-urgent group mailbox throughout the day and appropriately re-assigns referrals and follow up to team members the same day of request.
• Updates TruCare Contacts when members transition between care team members ensuring accurate care team membership as directed by Clinical Leader.
• Scans multiple types of documents into the TruCare system utilizing established protocols

Member Related Supportive Functions (detailed and unique to role):

• Manages various queues in the TruCare system following established processes, including but not limited to the SCO LTC Queue for all NaviCare Short Term Custodial and Long Term Care admission/discharge/extension related communication, the Collective Medical Queue for ACO members.
• Manages the TruCare ‘CM Intake Queue’ following established processes and assigns members to Clinical Integration Team staff for outreach and action
• Receives and processes NaviCare member address change and phone number change requests utilizing a centralized mailbox in Outlook and communicates such to interdepartmental teams via QNXT Call Tracking
• Receives requests for ACO member handbooks and other approved materials and communicates such to interdepartmental teams via QNXT Call Tracking
• Utilizes Smart Data for processing invoices for interpreter services
• Receives and processes incoming vendor invoices ensuring members receiving services at such point in time have active membership
• Provides additional support to the ACO Community partner (CP) and Flex Program Coordinator as needed and directed by Supervisor/Manager.

TruCare System Access Related Functions – Vendor Management Functions:

• Reconciles monthly NaviCare ASAP rosters in preparation for automated sending and corrects and resends ASAP rosters when discrepancies are identified maintaining master rosters on the group drive
• Manages incoming requests from vendors/ASAPs/providers for access to the TruCare Documentation system performing reconciliations with vendors/ASAPs/providers
• Manages deactivation for vendor/ASAP/provider TruCare users when access no longer required in conjunction with I.T. department
• Generates and updates rosters of vendor/ASAP/provider TruCare users
• Manages deactivation for ACO TruCare users when access no longer required in conjunction with I.T. department
• Generates and distributes reports for various contracted partners including but not limited to: Long Term Care Facilities, Adult Day Health Care Providers, Adult Foster Care Providers, Physician Practice Sites, and others as required

Reporting Related Functions:

• Obtains the Daily NaviCare Discharge Report from the Collective Medical Portal, formats the report to a user-friendly view, saves it in the appropriate G-drive folder and distributes the report by email to all staff working on the NaviCare product
• Obtains the Daily ACO Discharge Report from the Collective Medical Portal, formats the report to a user-friendly view, saves it in the appropriate G-drive folder and distributes the report by email to the ACO Community Partners and once approved, re-assigns tasks to appropriate staff working on the ACO products
• Receives monthly Long Term Care Rating Category discrepancy file and manipulates and sends to the appropriate Long Term Care Navigator to work with the facilities maintaining up to date information on new, closed, and pending discrepancies 
• Runs the NaviCare Long Term Care membership report from Business Objects and manipulates per process and sends to Senior Accounting Analyst, designated long term care facilities, and NaviCare Sales Team

 Other Functions:

• Adheres to Fallon Health requirements for time clock use and time entry
• Engages in extensive contact with all levels of personnel in a professional and confidential manner
• As requested, promptly and courteously receives visitors to department or assists Program Department Administrative Assistant with meetings, department functions, and other activities
• Supports department colleagues, covering and assuming changes in assignment as assigned by Manager/designee
• Strictly observes HIPAA regulations and the Fallon Health policies regarding confidentiality of member information
• Supports and helps any member of the Clinical Integration Team Leadership team with any other supportive requests to meet Program needs
• Performs other responsibilities as assigned by the Manager/designee

Education:

College degree preferred; Minimum of high school diploma required

License/Certifications

Other:  Satisfactory Criminal Offender Record Information (CORI) results

Experience:

2+ years job experience in an administrative supportive role required.  Experience with medical terminology required.  Experience in a healthcare company required.   

Demonstrated proficiency including but not limited to:

• Use of software programs including but not limited to Excel, Word, and other computerized systems utilized for documenting activity and actions including but not limited to scanning and generating correspondence – ability to type/utilize keyboard with speed and accuracy
• Ability to prepare and manipulate spreadsheets (with or without pivot tables)
• Effective collaboration, teamwork, communication, and change management skills
• Attention to detail and accuracy of work output
• Ability to provide input to step by step process document creation and updating
• Ability to recognize and recommend process changes to enhance efficiency of output and team production

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.