Medicare​/Community Care Nurse Case Manager

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, 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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Summary of purpose:

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, specifically for Medicare and Community Care membership. The NCM seeks to establish telephonic relationships with the member/caregiver(s) to better ensure ongoing service provision and care coordination, consistent with member specific needs and quality metrics developed by the NCM and support team.

Responsibilities may include regular telephonic assessments, care planning and identifying member specific priorities, and assessments with the goal to coordinate and facilitate services to meet member needs according to benefit structures and available community resources. The NCM must be familiar with quality metrics including STARS and HEDIS as well as guiding factors within the NCQA standards. Emphasis is placed on complex case management, reducing readmission rates and ensuring that members’ needs are met at time of transition from ER/inpatient hospitalization to home.

The NCM must understand the effect that social determinants of health have on health outcomes, identify barriers to remaining safe in the community and align members with community supports to meet SDOH needs. The NCM is also required to have an understanding of the benefit structure for both Medicare and Community Care.

Primary Job Responsibiities

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

• Member Assessment, Education, and Advocacy
  • Telephonically assesses and manages a member panel
  • Conducts cold calls to members identified as having a potential need for case management
  • Regular assessment of members’ needs, utilizing a variety of interviewing techniques, including motivational interviewing, and employs culturally sensitive strategies to assess a member’s clinical/functional status to identify ongoing special conditions and develops and implements an individualized, coordinated care plan, in collaboration with the member, the support team, community resources and providers
  • Performs medication reconciliations
  • Performs Care Transitions Assessments – per program and product line processes
  • Assesses for risk for readmission utilizing tools like Point Click Care
  • Participates in multidisciplinary rounds
  • Ensure members preventive health metrics are complete to close HEDIS gaps in care
  • Creates complex care plans and assessment in accordance with NCQA standards
  • Maintains up to date knowledge of 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 for both Medicare and Community 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…