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Form of workOverview:
About Fallon Health:
License/Certifications:
Experience:
Fallon Health Vaccination Requirements:
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.
The ACO Nurse Case Manager will be working hybrid remote! This position may require working in an Atrius medical office 1 day/week in either Boston or Quincy and the other days will be able to work from home.
About Fallon Health:
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 delivers equitable, high-quality coordinated care and is continually rated among the nation’s top health plans for member experience, service, and clinical quality. 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:
FallonHealth ACO program is looking for Nurse Case Manager (NCM) to provide enhanced care coordination/ complex case management to our members. The NCM will work with a multi-disciplinary team to provide person centered care planning and work collaboratively with community partners, PCP’s, state agencies, and other community supports. The NCM is an integral part on an interdisciplinary team focused on care coordination, care management and improving access to and quality of care for Fallon members. 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 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 may conduct assessments and may determine the number of hours’ members require for MassHealth programs such as the personal care attendant program, adult foster care, group adult foster care, and other programs per product benefits and guidelines. The NCM may utilize an ACD line to support department and incoming/outgoing calls with the goal of first call resolution with each interaction.
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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
- Utilizing clinical judgment and nursing assessment skills, may complete NaviCare Program Assessment Tools and Minimum Data Set Home Care (MDS HC) Form when a member’s medical/functional status changes that warrants a change in rating category to ensure members are in the correct State defined rating category
- Maintains up to date knowledge of Program and 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
- 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 such initiatives involving Key Metrics outreach
- 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 Navigator to ensure the member approves their care plan
- Manages NaviCare members in conjunction with the Navigator, Behavioral Health Case Manager, Aging Service Access Point Geriatric Support Service Coordinator, contracted Primary Care Providers and others involved/authorized in the member’s care
- 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 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 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
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/Certifications:
- License: Active, unrestricted license as a Registered Nurse in Massachusetts & current Driver’s license and a vehicle to be used for home visits
- Certification: Certification in Case Management strongly desired
- Other: Satisfactory Criminal Offender Record Information (CORI) results
Experience:
- 2+ years of clinical experience as a Registered Nurse working with people up to age 65 with a focus on working with people that are on MassHealth coverage and may be encountering social, economic, and/or multi complex medical and or behavioral health conditions required
- Ability to communicate and collaborate with PCP, community and ACO partners to manage members care required
- Experience working in a community social service agency, skilled home health care agency, State Agency such as the Department of Mental Health (DMH), Department of Developmental Services (DDS), Department of Children and Families (DCF), and/or the Department of Youth Services (DYS), or other agency servicing those in need preferred
- 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 case management requirements preferred
Competencies:
- Demonstrates commitment to the Fallon Health Mission, Values, and Vision
- Specific competencies essential to this position:
- Asks good questions
- Critical thinking skills, looks beyond the obvious
- Problem Solving
- 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
- Is able to write clearly and succinctly in a variety of communication settings and styles
Fallon Health Vaccination Requirements:
To protect the health and safety of our workforce, members and communities we serve, Fallon Health now requires all employees to disclose COVID-19 vaccination status. As of 2/1/2022 all roles not designated as “Remote” require full COVID-19 vaccination and Fallon Health will obtain the necessary information from candidates prior to employment to ensure compliance. Failure to meet the vaccination requirement may result in rescission of an employment offer or termination of employment.
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.
