Navigator; Temporary

Care Navigator (Temporary) Overview

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, we deliver equitable, high-quality coordinated care and are continually rated among the nation's top health plans for member experience, service, and clinical quality.

Fallon Health's Navi Care is a program for people age 65 and older, who live in our service area, and who have Mass Health Standard, and may have Medicare. It combines Mass Health (Medicaid) and Medicare benefits, including prescription drug coverage. At Fallon Health, 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- in the region.

Brief summary of purpose: The Navigator-Care Management is part of an interdisciplinary care team that coordinates care, improves access, and supports quality outcomes for Navi Care 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.

Primary Responsibilities

Member Education, Advocacy, and Care Coordination

• Conduct phone and, as appropriate, in-person assessments, screenings, and visits using Tru Care; 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); elevate 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.

Provider Partnerships and Collaboration

• 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.

Access to Care

• 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.

Care Team Communication

• 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.

Regulatory Requirements, Documentation, and Reporting

• 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 Tru Care and related systems; review and validate member panel data and reports.

Additional Responsibilities

• Maintain…