Fallon Health ACO Team Nurse Case Manager in Worcester, Massachusetts
Passionate about Helping People? Enjoy working with individuals experiencing complex health needs? Looking for No Weekends/ No Holidays & Work/Life Balance? Would enjoy working remotely?
About Fallon Health
Founded in 1977, Fallon Health is a leading health care services organization that supports the diverse and changing needs of those we serve. In addition to offering innovative health insurance solutions and a variety of Medicaid and Medicare products, we excel in creating unique health care programs and services that provide coordinated, integrated care for seniors and individuals with complex health needs. Fallon has consistently ranked among the nation’s top health plans, and is accredited by the National Committee for Quality Assurance for its HMO, Medicare Advantage and Medicaid products. For more information, visit fallonhealth.org.
Brief summary of purpose:
The Nurse Case Manager (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.
Responsibilities include but are not limited to:
Conducts engagement, outreach and education activities for patients identified as requiring case management services and care coordination.
Initiates telephonic contact with eligible members in order to conduct an initial assessment, patient/family health education, and develop a patient centered plan of care.
Manages ACO members in conjunction with the Navigators, Social workers, ACO clinical Partners, Community and 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 through a team model approach to coordinate a continuum of support consistent with the Member’s health care goals and needs
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.
Demonstrates positive customer service actions and takes responsibility to ensure member and provider needs are met.
Completes Program Assessments, Notes, Screenings, and Care Plans in the Centralized Enrollee Record according to product regulatory requirements and Program policies and processes.
Provide a central point of contact for member and providers, facilitating to meet member needs and transitions.
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.
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
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
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
Graduate from an accredited school of nursing mandatory 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
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 case management requirements preferred
AND IF Working with the Fallon Health ACO Member Population :
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
IF focused to work with the pregnant member population, 4+ years of clinical experience as a Registered Nurse working with pregnant females during the prenatal, delivery, and postpartum time required
If focused to work with the Cancer Care Program member population, 4+ years of clinical experience as a Registered Nurse working with oncology, hospice, and/or chemo infusion 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
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
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
Handles day to day work challenges confidently
Willing and able to adjust to multiple demands, shifting priorities, ambiguity, and rapid change
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.
Posted Date 1 month ago (6/18/2021 12:02 PM)
Job ID 6395
# Positions 1