Navigator, Senior Care - Worcester​/Milford - Spanish

Navigator, Senior Care Options – Worcester/Milford – Spanish Required

Join Fallon Health as a Navigator in our Senior Care Options team in Worcester or Milford. We are looking for a bilingual Spanish speaker with strong care coordination and customer service skills.

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 Navigator 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 Navigator partners with Fallon Health Care Team staff and other providers to always communicate what is occurring with the member and their status. The Navigator establishes telephonic and face‑to‑face relationships with the member/caregiver(s) and provider partners to better ensure ongoing service provision and care coordination, consistent with the member‑specific care plan.

The Navigator may make in‑home or facility visits, as appropriate, to fully understand a member’s care needs.

• Utilize an ACD line to support the department and handle incoming/outgoing calls with the goal of first‑call resolution.
• Conduct telephonic and, when necessary, face‑to‑face member visits to assess members using Tru Care Assessment Tools.
• Establish and develop effective working relationships with community partners (housing staff, adult day health care staff, assisted living staff, groups for adult foster care, rest home staff, long‑term care facilities, primary care providers) to facilitate member communication, represent Fallon Health positively, and grow membership in applicable products.
• Educate members and PRAs about their product benefits and how to access them, often coordinating access.
• Help members schedule and attend physician office visits.
• Place referrals and follow up to ensure services are in place per the individual care plan, and develop care plans with the Care Team; send member‑specific care plans per process.
• Perform care coordination, adhering to contact and duration frequencies, documenting all activities in Tru Care with correct assessment and note type following Clinical Integration Documentation Policy.
• Contact members to resolve gaps in care (e.g., PCP assignment, verification, preventive screenings, vaccination reminders).
• Assist members in obtaining access to care, arranging appointments, and following up to ensure attendance, identifying barriers and enabling attendance.
• Facilitate transportation for medical, behavioral health, and social appointments by educating members and, where required, completing the Mass Health PT‑1 process.
• Educate members and help obtain community benefits (food via EBT, fuel assistance, WIC).
• Screen members for social determinants of health (SDOH) and refer to Clinical Team members and partners for intervention based on criteria.
• For maternity members, facilitate delivery of items from the “Oh Baby” program and coordinate after‑care needs with Nurse Case Managers.
• Refer to the Nurse Case Manager or PCP when clinical decision‑making is required.

HS Diploma/GED required. College degree (BA/BS in Health Services or Social Work) preferred.

2+ years in a managed care company, medical‑related field, or community social service…