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:

• Managing a multi-location clinical team to ensure timely coordination of quality healthcare and care coordination services for Fallon Health members with varying levels of conditions
• Providing leadership, supervision, and support for direct report nursing and disease management staff fostering integration within care teams and member care plans
• Collaboratively working with Clinical Integration Leaders to implement Models of Care, Programs as outlined in Program Descriptions for various Fallon Health products ensuring adherence to CMS, State, NCQA, and other required elements

• Ensuring the Fallon Health members have an effective and compliant care plan to meet the member care needs according to product requirements working with clinical integration staff and leaders to ensure compliance and effectiveness of care plan
• Ensuring team performance goals are met and ensuring program staff are trained and compliant with departmental and policy requirements
• Educating direct reports on various levels of care coordination/case management interventions and recommending and supporting team actions to ensure effective member care plan development and implementation – active participant in Clinical Integration        Rounds
• Implementing quality improvement projects and strategies to support the Program in quality and performance measures including, but not limited to, NCQA, HEDIS, CMS, State, Medicare Five Star, External Quality Review projects,     etc.
• Participating in the preparation of member cases files for auditors, regulators, and others as required

• Participates in the management of designated provider and or vendor relationships asassigned, including but not limited to supporting embedded and enhanced providerpartnership relationships

• Partnering and participating in relationships with State Agencies such as Aging Service Access Points, Adult Day Health Care, Group Adult Foster Care, Adult Foster Care, Long Term Care Providers, LTSS Providers, Provider groups, and other vendors and               providers fostering collaborative working relationships
• Works with Manager to recommend changes to the case management system platform structure (CaseNET TruCare System) in conjunction with division leaders, Fallon Health I.T. and recommends modifications for workflow efficiencies and reporting                     enhancements based upon team experiences

Team Management:
• Hires, orients, trains, supervises, evaluates, counsels and terminates staff that function within the assigned Team in conjunction with the Manager
• Provides education to the Team on the various Fallon Health Products, various Models of Care, policies, processes, workflows, and best practices to support member care and Team processes
• Oversees performance of Team ensuring Program and Team goals are met utilizing reports and facilitating team independent use of such
• Establishes Team member productivity and professional goals in conjunction with the Manager
• Evaluates staff performance based on these defined goals and implements coaching and performance improvement measures and actions when necessary in conjunction with the Manager
• Develops workflows and educates Team on workflows as appropriate
• Monitors Team adherence to established workflows and implements improvements and workflow modifications as required
• Meets 1:1 with Direct Reports at least monthly and more frequently based upon need and utilizes established reports and systems to track and ensure performance to Team member and Program goals
• Works with Manager and audits Team member documentation for accuracy, timeliness, appropriateness, and adherence to workflow and works with staff to implement corrective   action as warranted
• Ensures staff utilize an effective communication style and methods to engage members/personal representatives in care management

• Facilitates and/or co-leads Team huddles up to three times per week – Team huddle content includes but is not limited to Fallon Health member review and brainstorming to meet care     plan needs; process development and enhancement; implementation of       new duties and tasks; reassignment of work to meet department needs and involvement of navigator and behavioral health case manager resources as appropriate
• Ensures department team members work collaboratively, shifting workloads and duties to meet Team needs
• In conjunction with Manager, recommends, develops, and may work with TruCare I.T.  Development team to ensure case management documentation system effective to meet Program needs

Program Leadership Activities – Quality Improvement Focus (as assigned)
• Participates in, and implements quality improvement projects
• Ensures team members follow workflow and reporting requirements to support projects and outcome requirements of programs including but not limited to Transition of Care and             Emergency Room utilization
• Generates and or utilizes reports to ensure Team performance to goal
• Utilizes reporting software to generate process measure reports for team performance oversight and teaches team members to be proficient utilizing reporting software to produce their own reports

Other:
• Works collaboratively and cohesively with all members of the care team (both internal and external staff and providers)
• Maintains an ongoing awareness of clinical, social, and financial resources available in the community
• 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
• Performs other responsibilities as assigned by the Manager/designee

Education:

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

License: Active, unrestricted license as a Registered Nurse in Massachusetts
Certification: Certification in Case Management strongly desired
Other: Satisfactory Criminal Offender Record Information (CORI) results; reliable transportation

Experience:

• A minimum of two years’ clinical experience as a licensed Registered Nurse managing/coordinating/facilitating/providing care for member populations required
• Experience working in a healthcare setting as a member of a professional team coordinating care for adult populations who are diagnosed with health conditions or chronic disease, including mental illness of substance use disorders required
• Familiarity with in home services both skilled and non-skilled, outpatient services including medical and behavioral health, knowledge of different levels of care including but not limited to acute, rehab, long term, and experience with Medicare and Medicaid coverage          criteria and requirements required
• One year of supervisory or management experience in a health care setting; preferably with experience supervising/managing staff preferred
• Two years’ experience performing care coordination in a managed care setting preferred
• Experience developing policies, procedures, and workflows preferred
• Experience with performance improvement projects including but not limited to establishing criteria for report queries, utilizing objective data to improve processes, and implementation of     projects preferred
• Experience with improvement methodologies including but not limited to lean and six sigma a plus

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.