Navigator, Clinical Integration

Responsibilities

Note:

Job Responsibilities may vary depending upon the member’s Fallon Health Insurance Product

• Member Education, Advocacy, and Care Coordination

• Utilizes an ACD line to support department and incoming/outgoing calls with the goal of first call resolution with each interaction

• Performs tasks and actions to ensure all CMS and State member related regulatory mandates are met including but not limited to welcome calls, care plans, health risk assessments/care needs screening for the member population, and member service plans according to Program Policy and Process for the particular member product

• Monitors the daily inpatient census and notifies all members of the care team during member care transitions including any discharge planning updates depending upon the product process

• Works collaboratively with Embedded Navigators and Transition of Care Team RNs

• Follows up with members following transition of care to ensure member attended follow up appointments, if they have any questions or concerns, and ensures all members of the Care Team are knowledgeable about the care transition and work collaboratively to ensure the member care plan meets needs

• May conduct visits to hospital and Nursing Facilities during a Care Transition to participate in the discharge planning process (depending upon the product and circumstances)

• May perform home visits with members (depending upon the product and circumstances). Visits may be by self, or with others on the Care Team

• Responds promptly to member calls/questions and follows up per department processes at all times demonstrating exceptional customer service skills in a culturally sensitive way

• Provides culturally appropriate care coordination i.e.: arranges for interpreters, provides communication documents in appropriate language, demonstrates culturally appropriate behavior when working with member/family

• Develops and fosters relationships with members and providers/facilities and depending upon the product, to be the first point of contact for benefit related questions and is able to explain processes including but not limited to: coverage criteria, appeal rights and processes, authorization request process, formulary, and evidence of coverage details

• Manages member panel in conjunction with other employed Clinical Integration Team members; depending on the Fallon Health product, with the contracted Aging Service Access Point Geriatric Support Service Coordinator when applicable; and/or Community Partners; and contracted primary and specialty care providers — this includes conducting face to face or telephonic health risk assessments in a culturally sensitive way, completing care plans, and reviewing claims and other data which may indicate a need for Nurse Case Manager involvement and assessment

• Assists the interdisciplinary team in identifying and addressing member barriers related to social determinants of health and care obtainment

• Collaborates with the interdisciplinary team in identifying and addressing high risk members and transitions of 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 community senior/cultural centers and other external partners

• Maintains up to date knowledge of Program/Product 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

• Participates in member retention efforts by providing benefit advice and clarification upon knowledge of member dissatisfaction and potential to voluntarily leave the plan, as applicable

• Collaborates with appropriate team members to ensure health education/disease management information is provided as identified

• Educate members on preventative screenings and other health care procedures such as vaccines and screenings…