Nurse Case Manager - Senior Care - Lowell

Nurse Case Manager - Senior Care Options - Lowell

Join to apply for the Nurse Case Manager - Senior Care Options - Lowell role at Fallon Health.

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.

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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. The NCM establishes telephonic and/or face‑to‑face relationships with the member/caregiver(s) to better ensure ongoing service provision and care coordination, consistent with the member‑specific care plan developed by the NCM and Care Team.

Responsibilities may include conducting in‑home face‑to‑face visits for members identified as needing visit interaction and assessments with the goal to coordinate and facilitate services to meet member needs according to benefit structures and available community resources. The NCM may conduct assessments and determine the number of hours members require for Mass Health programs such as the personal care attendant program, adult foster care, group adult foster care, and other programs per product benefits and guidelines.

The NCM may utilize an ACD line to support department and incoming/outgoing calls with the goal of first‑call resolution with each interaction.

• Telephonically assesses and case manages a member panel.
• May conduct in‑home face‑to‑face visits for onboarding new enrollees and reassessing members, utilizing a variety of interviewing techniques, including motivational interviewing, and employing culturally sensitive strategies to assess a member’s clinical/functional status to identify ongoing special conditions and develop and implement an individualized, coordinated care plan, in collaboration with the member, the Clinical Integration team, and Primary Care Providers, Specialists and other community partners, to ensure a cost‑effective quality outcome.
• Performs medication reconciliations.
• Performs Care Transitions Assessments – per Program and product line processes.
• Utilizes clinical judgment and nursing assessment skills, may complete Navi Care Program Assessment Tools and Minimum Data Set Home Care (MDS HC) Form when a member’s medical/functional status changes that warrants a change in rating category to ensure members are in the correct state‑defined rating category.
• Maintains up‑to‑date knowledge of Program and 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.
• 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…