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 Custodial Nurse Case Manager (NCM) is a key member of the Clinical Integration Team, overseeing Fallon Health members in both Long-Term and Short-Term Custodial care. The NCM collaborates with care teams and facilities to ensure MassHealth criteria are met, supports rehabilitation efforts, and facilitates safe transitions back to the community. Responsibilities include reviewing care plans, conducting facility visits, updating care teams, and developing individualized care plans for long-term residents, including behavioral and rehabilitative services.

Primary Job Responsibilities

Utilization Review and Care Coordination and Collaboration

• Clinical oversight of NaviCare members who reside in Long-Term Care or Short-Term Custodial settings.
• Performs in-person facility visits for assigned panel of members, at a frequency per contract and program requirements, and/or member clinical needs.
• Perform and complete comprehensive assessments as required by contract.
• Reviews MDS 3.0 assessments completed by facility staff, ensuring that clinical documentation aligns with member conditions, health status and rating category/level of care.
• Evaluate for unmet behavioral health or social determinants of health needs and refer to Behavioral Health as needed.
• Completes ongoing review of facility assessments, identifies members who have had a change in status and ensures members are rated at the appropriate levels of care.
• Participate in family meetings, prioritizing meetings for complex members who need support to transition back to community.
• Collaborate with nursing home staff and leadership to develop plans to reduce hospital admissions, readmissions, and ED utilization.
• In collaboration with member/authorized representative(s) develop a member centric care plan for each LTC member with a focus on specific needs to maintain the member at the highest level of independence and safety.
• Identify significant changes in member status, ensuring timely updates to care plans and assessments.
• Support transitions of care, including discharge planning and coordination with community resources.
• Collaborate with facility staff to coordinate services and help members meet their goals.
• Manages custodial care members in conjunction with the Navigator, Behavioral Health Case Manager, Social Care Manager, contracted Primary Care Provider, and others involved/authorized in member’s care.
• Conducts clinical reviews of the member’s facility care plan to ensure MassHealth criteria for short term custodial care is met and works with long term care facilities to implement a timely and effective discharge plan for the member to return to the community.
• Conducts concurrent utilization review for members that are in the short-term custodial level of care by reviewing clinical documentation and member details provided by facility.
• Works collaboratively with LTC Navigators to complete bed searches and submit medical documentation for members residing in the community who need to transition directly to STC level of care from home.

Regulatory Requirements – Actions and Oversight

Completes Program Assessments, Notes, Screenings, and Care Plans in the Centralized Enrollee Record according to product regulatory requirements and Program policies and processes.

Performs other responsibilities as assigned by the Manager/designee.

Supports department colleagues, covering and assuming changes in assignment as assigned by Manager/designee

• Graduate from an accredited school of nursing required 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
• Certification: Certification in Case Management strongly desired
• Other: Satisfactory Criminal Offender Record Information (CORI) results, reliable transportation

Experience

• 3+ years of clinical experience as a Registered Nurse managing chronically ill members or experience in a coordinated care program required.
• Knowledge of Skilled Nursing Facility/Long Term Care Facility benefits and processes required.
• Discharge planning experience required.
• Home Health Care experience preferred.
• Familiarity with CMS levels of care preferred.

Performance Requirements including but not limited to:

• Excellent communication and interaction with providers and members via telephone and in-person
• Exceptional customer service skills and willingness to assist ensuring timely discharge planning and resolution of issues.
• Excellent organizational skills and ability to multi-task
• Appreciation and adherence to policy and process requirements
• Independent learning skills and success with various learning methodologies including but not limited to self-study, mentoring, classroom, and group education.
• Knowledgeable about community resources available to assist the member population in the community and long-term care settings and demonstrated willingness to seek resources and expand knowledge to assist the population.
• Knowledgeable about insurance regulatory and accreditation requirements
• Effective case management and care coordination skills
• Excellent Physician and other health care provider interaction and other communication including but not limited to face to face communication.
• Ability to lead and represent the health plan and Clinical Integration team when participating in facilities in member discharge planning rounds.
• Ability to mentor and train others
• Proficient in software systems including but not limited to Microsoft Office Products – Excel, Outlook, and Word
• Proficient in manipulating Excel spreadsheets to manage work and exposure and familiarity with pivot tables.

Competencies:

• Demonstrates commitment to the Fallon Health Mission, Values, and Vision
• Specific competencies essential to this position:
• Problem Solving
• Asks good questions.
• Critical thinking skills, looks beyond the obvious
• Adaptability
• Manages day-to-day work challenges confidently.
• Willing and able to adjust to multiple demands, shifting priorities, ambiguity, and rapid change.
• Demonstrates flexibility.
• Written Communication
• Is able to write clearly and succinctly in a variety of communication settings and styles

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.