Medicare/Community Care Nurse Case Manager - Hybrid Remote

Fallon Health•Worcester, MA

4d•$88,000 - $95,000•Hybrid

About The Position

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, Fallon Health delivers equitable, high-quality, coordinated care and is continually rated among the nation’s top health plans for member experience, service, and clinical quality. 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 (Program of All-Inclusive Care for the Elderly)— in the region. Learn more at fallonhealth.org or follow us on Facebook, Twitter and LinkedIn. Summary of purpose: The Nurse Case Manager (NCM) is an integral part of an interdisciplinary team focused on care coordination, care management and improving access to and quality of care for Fallon members, specifically for Medicare and Community Care membership. The NCM seeks to establish telephonic relationships with the member/caregiver(s) to better ensure ongoing service provision and care coordination, consistent with member specific needs and quality metrics developed by the NCM and support team. Responsibilities may include regular telephonic assessments, care planning and identifying member specific priorities, and assessments with the goal to coordinate and facilitate services to meet member needs according to benefit structures and available community resources. The NCM must be familiar with quality metrics including STARS and HEDIS as well as guiding factors within the NCQA standards. Emphasis is placed on complex case management, reducing readmission rates and ensuring that members’ needs are met at time of transition from ER/inpatient hospitalization to home. The NCM must understand the effect that social determinants of health have on health outcomes, identify barriers to remaining safe in the community and align members with community supports to meet SDOH needs. The NCM is also required to have an understanding of the benefit structure for both Medicare and Community Care.

Requirements

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 and reliable transportation
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 with telephonic interviewing skills and working with a diverse population, that may also be non-English speaking, required
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
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, look 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
Able to write clearly and succinctly in a variety of communication settings and styles
Oral Communication
Able to effectively communicate with members, providers and community supports
Effective interviewing skills to draw information from members to create cohesive and effective care plans

Nice To Haves

Experience working face to face with members and providers preferred
Home Health Care experience preferred
Familiarity with NCQA, CAHPS and Stars/HEDIS metrics preferred

Responsibilities

Member Assessment, Education, and Advocacy
Telephonically assesses and manages a member panel
Conducts cold calls to members identified as having a potential need for case management
Regular assessment of members’ needs, 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 support team, community resources and providers
Performs medication reconciliations
Performs Care Transitions Assessments – per program and product line processes
Assesses for risk for readmission utilizing tools like PointClickCare
Participates in multidisciplinary rounds
Ensure members preventive health metrics are complete to close HEDIS gaps in care
Creates complex care plans and assessment in accordance with NCQA standards
Maintains up to date knowledge of 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 for both Medicare and Community Care
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
Identifies and refers members to other Fallon Health products as appropriate
Must maintain working knowledge of all products offered at Fallon Health, including but not limited to NaviCare, ACO and Summit
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
Identifies SDOC needs and appropriately collaborates with community partners to ensure needs are being met
Manages members who are at risk for Medication non-compliance by working closely with the Fallon pharmacy team and outreaching members as needed
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
Manages members in conjunction with the Navigator, Behavioral Health Case Manager, and community supports as appropriate
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 Pharmacy team, referring members in need of medication review based upon member need
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
Acts as an advocate for members ensuring that their medical needs are being met in an effective manner
Identifies social determinate of health needs and works cohesively with the care team and external supports to help close these disparities
Actively participates in clinical rounds
Provider Partnerships and Collaboration
Ensures providers are updated with any critical health issues
Advocates for member needs with providers as needed
Educates members on quality gaps in care as needed
Demonstrates positive customer service actions and takes responsibility to ensure member and provider requests and needs are met
Familiarizes oneself with multiple provider and facility electronic medical records to obtain and review member records
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
Familiarizes oneself with CAHPS questions to better ready members for survey
Is a subject matter expert in Complex Case Management to meet NCQA standards
Performs other responsibilities as assigned by the Manager/designee
Supports department colleagues, covering and assuming changes in assignment as assigned by Manager/designee