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 Accountable Care Organization (ACO) Nurse Case Manager (NCM) is an integral part on an interdisciplinary team focused on transition of care assessment and support, care coordination, care management and improving access to and quality of care for Fallon Health ACO members.

The NCM embeds in the ACO Partner Provider Offices and works closely with ACO Partner Providers, Office Staff, Care Management Staff and others at the Partner sites managing member care.

NCM seeks to establish telephonic and/or face to face relationships with the member/caregiver(s) to better ensure ongoing service provision and care coordination, consistent with the member specific care plan developed by the NCM and Care Team.  

Responsibilities may include conducting in home/office face to face visits for member identified as needing face to face visit interaction and assessments with the goal to coordinate and facilitate services to meet member needs according to benefit structures and available community resources.  The NCM conducts assessments and refers members to Community Partner Programs such as Behavioral Health and Long-Term Services and Supports.  The NCM may also refer members to Flex Program as applicable depending upon the ACO the member is affiliated with.  The NCM may utilize an ACD line to support department and incoming/outgoing calls with the goal of first call resolution with each interaction.

Primary Job Responsibilities

Member Assessment, Education, and Advocacy

• Telephonically assesses and case manages a member panel
• May conduct in home face to face visits for onboarding new enrollees and reassessing members, utilizing a variety of interviewing techniques, including motivational interviewing, and employs culturally sensitive strategies to assess a Member’s clinical/functional status to identify ongoing special conditions and develops and implements an individualized, coordinated care plan, in collaboration with the member, the Clinical Integration team, and Primary Care Providers, Specialist and other community partners, to ensure a cost effective quality outcome
• Performs medication reconciliations
• Performs Care Transitions Assessments – per Program and product line processes
• Maintains up to date knowledge of Program and product line benefits, Plan Handbook Benefits and Coverage 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
• 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 senior centers and other external partners
• Follows department and regulatory standards to authorize and coordinate healthcare services ensuring timeliness in compliance with documented care plan goals and objectives
• Assesses the Member’s knowledge about the management of current disease processes and medication regimen, provides teaching to increase Member/caregiver knowledge, and works with the members to assist with learning how to self-manage his or her health needs, social needs or behavioral health needs
• Collaborates with appropriate team members to ensure health education/disease management information is provided as identified
• Collaborates with the interdisciplinary team in identifying and addressing high risk members
• Educate members on preventative screenings and other health care procedures such as vaccines, screenings according to established protocols and program processes
• Ensures members/PRAs participate in the development and approval of their care plans in conjunction with the interdisciplinary primary care team
• Strictly observes HIPAA regulations and the Fallon Health Policies regarding confidentiality of member information
• Supports Quality and Ad-Hoc campaigns

Care Coordination and Collaboration

• Provides culturally appropriate care coordination, i.e., works with interpreters, provides communication approved documents in the appropriate language, and demonstrates culturally appropriate behavior when working with member, family, caregivers, and/or authorized representatives
• With member/authorized representative(s) collaboration develops member centered care plans by identifying member care needs while completing program assessments and working with the member to approve their care plan
• Manages ACO members in conjunction with the Navigator, Social Care Managers, ACO Partners, Community Partners, Behavioral Health Partners and others involved/authorized in the member’s care
• Monitors progression of member goals and care plan goals, provides feedback and 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
• Works collaboratively with Fallon Health Pharmacist, referring members in need of medication review based upon Program process
• Develops and fosters relationships with members, family, caregivers, PRAs, vendors and providers to ensure good collaboration and coordination by streamlining 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
• Actively participates in clinical rounds 

Provider Partnerships and Collaboration

• May attend in person member/provider visits, care plan meetings with providers and office staff and may lead care plan review with providers and care team as applicable
• Demonstrates positive customer service actions and takes responsibility to ensure member and provider requests and needs are met

Regulatory Requirements – Actions and Oversight

• Completes Program Assessments, Notes, Screenings, and Care Plans in the TruCare and Provider EMR systems according to Program policies and processes 

Other

• Performs other responsibilities as assigned by the Manager/designee
• Supports department colleagues, covering and assuming changes in assignment as assigned by Manager/designee

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/Certification

License:  Active, unrestricted license as a Registered Nurse in Massachusetts; current Driver’s license and reliable transportation

Certification: Certification in Case Management strongly desired

Resources: Microsoft Office products including but not limited to:  Excel, PowerPoint, Word, Outlook; Visio, Business Objects, QNXT, TruCare, Collective Medical, and other applications including provider EMRs

Other:  Satisfactory Criminal Offender Record Information (CORI) results.

This role requires compliance with the ACO Partner Health and Educational requirements.

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.