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, we deliver equitable, high-quality coordinated care and are continually rated among the nation’s top health plans for member experience, service, and clinical quality.

Fallon Health’s NaviCare is a program for people age 65 and older, who live in our service area, and who have MassHealth Standard, and may have Medicare. It combines MassHealth (Medicaid) and Medicare benefits, including prescription drug coverage. At Fallon Health, 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— in the region.

Brief summary of purpose: 

The Clinical Integration Support Navigator is an internal-facing role responsible for navigating members, facilities, and internal teams through the Clinical Integration (CI) care management system. This role serves as a centralized navigation, coordination, and triage function, ensuring accurate routing, documentation, and workflow adherence across the CI continuum.

The Support Navigator acts as an operational anchor within the care management models supporting efficient care delivery by removing system and process barriers, maintaining data integrity, and facilitating timely, accurate handoffs between team members.

Primary Responsibilities

Member Education, Advocacy, and Care Coordination

• Educate members and providers on care plans, covered benefits, program requirements, and Plan Evidence of Coverage.
• Respond to member inquiries and support navigation of the care management system using culturally sensitive, customer‑focused communication.
• Support member engagement and understanding of disease management, preventive care, and identified gaps in care.

Provider Partnerships and Collaboration

• Communicate effectively with primary care practices, provider groups, facilities, and vendors to support coordinated care delivery.
• Build and maintain positive working relationships with providers to address member needs and service requests.
• Distribute and maintain accurate provider and membership reports to support care coordination and panel management.
• Collaborate with external partners, including contracted vendors, to facilitate timely service delivery.

Access to Care

• Initiate and support service requests in alignment with the member care plan.
• Assist with authorization processes by ensuring required documentation is submitted accurately and timely.
• Educate providers on authorization workflows and outcomes, and help resolve authorization‑related issues.
• Follow through to confirm that authorized services are in place and accessible to members.

Care Team Communication

• Serve as a centralized coordination point for care team communication across the Clinical Integration model.
• Monitor queues, reports, and workflows to triage and route member needs to appropriate care team members.
• Support transitions of care by communicating with facilities, providers, and internal teams during admissions, discharges, and care setting changes.
• Partner with Long‑Term Care and Community Teams to support admission and discharge planning for members transitioning across care settings.

Regulatory Requirements – Actions and Oversight

• Ensure compliance with CMS, State, Model of Care, HEDIS, and Medicare Star requirements.
• Communicate member care plans to primary care providers within required regulatory timeframes.
• Maintain accurate, timely documentation within care management systems, including TruCare and associated reports.
• Review, validate, and update member panel data to ensure accuracy of contacts, services, and program enrollment.
• Obtain, upload, and maintain medical records and required documentation to support care management and regulatory audits.

Education: 

College degree (BA/BS in Health Services or Social Work) preferred

License/Certifications

License: N/A

Certification: N/A 

Other: Satisfactory Criminal Offender Record Information (CORI) results and access to reliable transportation

Experience: 

• Minimum 2 years’ experience in managed care, medical, or community social service settings
• Understanding of hospitalization, discharge planning, and post-acute needs
• Knowledge of medical terminology, documentation, and disease processes
• Ability to recognize clinical triggers requiring RN involvement
• Experience with motivational interviewing and diverse/non-English-speaking populations
• Knowledge of social determinants of health
• Proficiency with Microsoft Office (Excel, Word, Outlook)

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.