Care Navigator (Temporary)

Fallon Health•Worcester, MA

12d•Hybrid

About The Position

The Navigator–Care Management is part of an interdisciplinary care team that coordinates care, improves access, and supports quality outcomes for NaviCare members. The Navigator builds relationships with members/caregivers via phone and in person, conducts home visits as needed, helps implement care plan interventions, and works to remove barriers to care. In partnership with the Nurse Case Manager, the Navigator updates care plans and provides holistic case management for low-, moderate-, and high-risk members.

Requirements

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)
Satisfactory Criminal Offender Record Information (CORI) results
Access to reliable transportation

Nice To Haves

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

Responsibilities

Conduct phone and, as appropriate, in-person assessments, screenings, and visits using TruCare; update individualized care plans and aim for first-contact resolution in a culturally responsive manner.
Coordinate and follow up on care needs, including post-transition outreach, appointment scheduling, medication support, and service monitoring.
Educate members/representatives on benefits, coverage criteria, rights, appeals, authorizations, and evidence of coverage.
Identify and address gaps in care (e.g., PCP assignment, preventive screenings, vaccinations) per established protocols.
Screen for social determinants of health and refer to community resources (e.g., food, housing, fuel assistance, transportation); escalate clinical decisions to the Nurse Case Manager or PCP.
Advocate for members’ access to covered benefits and coordinate with community agencies for non-covered supports.
Participate in—and as appropriate, lead—care plan meetings with providers, partners, and care team members.
Collaborate with the interdisciplinary team (e.g., LTC, behavioral health, advanced practitioners, community partners) to support coordinated care.
Build effective working relationships with community partners and providers (e.g., housing, ADH, assisted living, LTC facilities, PCPs) to support timely, member-specific communication.
Submit and track requests/authorizations for covered services; ensure accuracy and timeliness per program workflows.
Educate members and providers on authorization processes and help resolve authorization issues.
Facilitate access to medical, behavioral health, and social services, including arranging transportation when needed.
Communicate timely updates with members, caregivers, providers, and internal teams on care plans, service changes, and member status.
Partner with LTC and community teams during admissions, transitions, and discharges to ensure continuity of care.
Complete required activities to meet CMS/State, NCQA, HEDIS, and other standards (e.g., welcome calls, screenings, care plans).
Document accurately and on time in TruCare and related systems; review and validate member panel data and reports.
Maintain knowledge of program benefits, policies, procedures, and community resources.
Support operations by covering assignments, adapting to priorities, and completing other duties as assigned.
Mentor or train staff on job-related processes and workflows, as assigned.