Senior Nurse Case Manager - Home Care Programs
About The Position
Fallon Health is a Worcester, Massachusetts-based health plan founded in 1977. Its mission is to improve health and inspire hope, with a focus on government-sponsored health insurance programs, including Medicare, Medicaid, and PACE. Fallon Health emphasizes equitable, high-quality, coordinated care and an inclusive workplace. The Senior Nurse Case Manager serves as the primary clinical subject matter expert and operational lead for In Home Clinical Services (IHCS) and the Personal Care Attendant (PCA) Program. The role provides clinical triage, case consultation, program oversight, regulatory guidance, and interdisciplinary collaboration to resolve complex member concerns in a timely manner and support compliance with state and organizational requirements. It acts as the single point of ownership for escalated IHCS and PCA issues, partnering with Nurse Case Managers, Navigators, LTSS teams, providers, vendors, and community partners to support member outcomes, operational efficiency, trend identification, and continuous improvement. The position combines responsibilities of a Nurse Case Manager, clinical triage specialist, program manager, and operational subject matter expert. It supports frontline staff by taking ownership of complex IHCS and PCA issues while they focus on direct member management.
Requirements
- Graduate from an accredited school of nursing; an associate’s degree is required.
- Active, unrestricted Registered Nurse license in Massachusetts.
- At least 3 years of clinical RN experience with complex medical, behavioral, and social co-morbidities.
- Ability to conduct assessments in person and by telehealth.
- Ability to work on interdisciplinary teams.
- Skill in screening social determinants of health.
- Strong communication and interviewing skills.
- Problem-solving skills and adaptability.
- Knowledge of regulatory requirements or willingness to learn them.
- Valid driver’s license.
- Must attest to having no disqualifiers under the Driver Safety Policy.
- Must possess and provide proof of minimum state-required auto insurance.
- Must have reliable transportation.
- Reliable home internet.
Nice To Haves
- Bachelor’s degree or higher.
- Certification in Case Management; certification is strongly desired, with willingness to obtain it when eligible.
- Experience in Home Health, OASIS/MDS, Medicare/Medicaid, or face-to-face member interactions.
Responsibilities
- Serve as the primary clinical liaison between Clinical Integration and IHCS.
- Represent Clinical Integration in IHCS meetings, case conferences, and operational workgroups.
- Review and triage complex IHCS referrals, service concerns, provider issues, and care coordination challenges.
- Facilitate interdisciplinary case consultations for members with complex clinical, behavioral, or social needs.
- Coordinate communication and follow-up between IHCS providers, care teams, and leadership.
- Identify service barriers, trends, and systemic issues affecting members receiving IHCS; recommend improvements to service delivery, communication, and member outcomes.
- Monitor IHCS performance, service utilization, and operational effectiveness.
- Serve as the organizational subject matter expert for the PCA Program and applicable MassHealth regulations.
- Manage escalated PCA requests, concerns, service disputes, and operational challenges.
- Lead Time-for-Task reviews and support clinical decision-making regarding PCA service needs.
- Review complex PCA assessments and assist staff in interpreting PCA eligibility guidelines.
- Consult on PCA eligibility determinations, service authorizations, appeals and denials, program compliance requirements, and EVV-related processes.
- Partner with LTSS, Utilization Management, and Medical Directors on complex PCA cases.
- Collaborate with EVV stakeholders to identify barriers and develop solutions related to PCA service delivery.
- Monitor trends in PCA approvals, appeals, service utilization, access barriers, and operational inefficiencies.
- Lead efforts to improve consistency and standardization of PCA-related processes.
- Provide expert consultation and support to Nurse Case Managers, Assessment Nurses, Navigators, Supervisors, and Leadership.
- Assist staff in resolving complex member situations involving functional needs, LTSS services, caregiver concerns, home-based support services, and regulatory requirements.
- Support member-centered care planning and service coordination.
- Participate in case rounds, clinical reviews, quality initiatives, and operational meetings.
- Escalate high-risk situations appropriately and ensure timely resolution.
- Monitor program performance metrics and identify improvement opportunities.
- Conduct audits of IHCS and PCA processes to ensure compliance and consistency.
- Analyze trends and develop recommendations for operational enhancements.
- Assist with developing and maintaining policies, procedures, workflows, and educational materials.
- Participate in readiness activities related to regulatory audits and program evaluations.
- Lead special projects and process improvement initiatives involving IHCS and PCA services.
- Conduct assessments in person and via telehealth as needed.
- Drive a personal motor vehicle as an essential job function and meet the stated driver safety, licensing, insurance, and transportation requirements.
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What This Job Offers
Job Type
Full-time
Career Level
Senior
Education Level
Associate degree
