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.

Summary of purpose: 

The Nurse Case Manager (NCM) is an integral part of an interdisciplinary team focused on care coordination, care management and improving access to and quality of care for Fallon members, specifically for Medicare and Community Care membership. The NCM seeks to establish telephonic relationships with the member/caregiver(s) to better ensure ongoing service provision and care coordination, consistent with member specific needs and quality metrics developed by the NCM and support team.   Responsibilities may include regular telephonic assessments, care planning and identifying member specific priorities, and assessments with the goal to coordinate and facilitate services to meet member needs according to benefit structures and available community resources.  The NCM must be familiar with quality metrics including STARS and HEDIS as well as guiding factors within the NCQA standards. Emphasis is placed on complex case management, reducing readmission rates and ensuring that members’ needs are met at time of transition from ER/inpatient hospitalization to home. The NCM must understand the effect that social determinants of health have on health outcomes, identify barriers to remaining safe in the community and align members with community supports to meet SDOH needs. The NCM is also required to have an understanding of the benefit structure for both Medicare and Community Care.

Primary Job Responsibiities

Note:  Job Responsibilities may vary depending upon the member’s Fallon Health Product

• Member Assessment, Education, and Advocacy
  • Telephonically assesses and manages a member panel
  • Conducts cold calls to members identified as having a potential need for case management
  • Regular assessment of members’ needs, 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 support team, community resources and providers
  • Performs medication reconciliations
  • Performs Care Transitions Assessments – per program and product line processes
  • Assesses for risk for readmission utilizing tools like PointClickCare
  • Participates in multidisciplinary rounds
  • Ensure members preventive health metrics are complete to close HEDIS gaps in care
  • Creates complex care plans and assessment in accordance with NCQA standards
  • Maintains up to date knowledge of product line benefits, Plan Evidence of 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 for both Medicare and Community 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 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
  • Identifies and refers members to other Fallon Health products as appropriate
  • Must maintain working knowledge of all products offered at Fallon Health, including but not limited to NaviCare, ACO and Summit
  • 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 such initiatives involving Key Metrics outreach
  • Identifies SDOC needs and appropriately collaborates with community partners to ensure needs are being met
  • Manages members who are at risk for Medication non-compliance by working closely with the Fallon pharmacy team and outreaching members as needed
  • 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
  • Manages members in conjunction with the Navigator, Behavioral Health Case Manager, and community supports as appropriate
  • 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 Pharmacy team, referring members in need of medication review based upon member need
  • 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
  • Acts as an advocate for members ensuring that their medical needs are being met in an effective manner
  • Identifies social determinate of health needs and works cohesively with the care team and external supports to help close these disparities
  • Actively participates in clinical rounds
• Provider Partnerships and Collaboration
  • Ensures providers are updated with any critical health issues
  • Advocates for member needs with providers as needed
  • Educates members on quality gaps in care as needed
  • Demonstrates positive customer service actions and takes responsibility to ensure member and provider requests and needs are met
  • Familiarizes oneself with multiple provider and facility electronic medical records to obtain and review member records
• 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
  • Knowledge of and compliance with HEDIS and Medicare 5 Star measure processes, performing member education, outreach, and actions in conjunction with the Navigator and other members of the Clinical Integration and Partner Teams
  • Familiarizes oneself with CAHPS questions to better ready members for survey
  • Is a subject matter expert in Complex Case Management to meet NCQA standards
• 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 mandatory and a Bachelors (or advanced) degree in nursing or a health care related field preferred.

License/Certifications

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 and reliable transportation

Experience: 

• 1+ years of clinical experience as a Registered Nurse managing chronically ill members or experience in a coordinated care program required
• Understanding of hospitalization experiences and the impacts and needs after facility discharge required
• Experience working face to face with members and providers preferred
• Experience with telephonic interviewing skills and working with a diverse population, that may also be non-English speaking, required
• Home Health Care experience preferred
• Effective case management and care coordination skills and the ability to assess a member’s activities of daily function and independent activities of daily function and the ability to develop and implement a care plan that meets the member’s need working in partnership with a care team preferred
• Familiarity with NCQA, CAHPS and Stars/HEDIS metrics preferred

 Performance Requirements including but not limited to:

• Excellent communication and interpersonal skills with members and providers via telephone and in person
• Exceptional customer service skills and willingness to assist ensuring timely resolution
• 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
• Working with an interdisciplinary care team as a partner demonstrating respect and value for all roles and is a positive contributor within job role scope and duties
• Willingness to learn insurance regulatory and accreditation requirements
• Knowledgeable about software systems including but not limited to Microsoft Office Products – Excel, Outlook, and Word
• Familiar with Excel spreadsheets to manage work and exposure and familiarity with pivot tables
• Accurate and timely data entry
• Effective case management and care coordination skills and the ability to assess a member’s activities of daily function and independent activities of daily function and the ability to develop and implement a care plan that meets the member’s need
• Knowledge about community resources, levels of care, criteria for levels of care and the ability to appropriately develop and implement a care plan following regulatory guidelines and level of care criteria
• Ability to effectively respond and adapt to changing business needs and be an innovative and creative problem solver

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, look beyond the obvious
  • Adaptability
    • Handles day-to-day work challenges confidently
    • Willing and able to adjust to multiple demands, shifting priorities, ambiguity, and rapid change
    • Demonstrates flexibility
  • Written Communication
    • Able to write clearly and succinctly in a variety of communication settings and styles
  • Oral Communication
    • Able to effectively communicate with members, providers and community supports
    • Effective interviewing skills to draw information from members to create cohesive and effective care plans

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.