Fallon Nursing Jobs

mobile fallon logo

Job Information

Fallon Health Nurse Case Manager for Medicaid ACO Program: Pediatric AND Family Focus - Remote 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, the Medicaid population, and individuals with complex health needs. Fallon currently partners with three large health care delivery partners to provide innovative services to the Medicaid population across Massachusetts. 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 willcoordinate and manage members’ care through multiple care delivery systems with a focus on children with complex and chronic health care needs and their families. Often acting as the central point of contact for members and their families, the RN case manager will conduct assessments and care plans, and provide case management services which facilitate the delivery of quality services. The RN Case manager will work as part of a multi-disciplinary team of social workers and care coordinators to support children and their families through transitions of care and to meet children’s complex health needs. The RN Case Manager collaborates with the member, family, medical providers, ACO delivery partners, community and state agencies, as well as other resources to address the comprehensive and complex needs of the child and family.

The Case Manager seeks to establish telephonic and face to face (depending upon product and circumstance) relationships with the member/caregiver(s) and provider partners to better ensure ongoing service provision and care coordination, consistent with the member specific care plan. While this position will have a primary focus on children and families, the team member will have the opportunity to work with members across the lifespan.



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:

  • Problem Solving

  • Asks good questions

  • Critical thinking skills, looks 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

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.


Location US-MA-Worcester

Posted Date 2 weeks ago (7/21/2021 4:07 PM)

Job ID 6419

# Positions 1

Category Nursing