Triage Case Manager - Hybrid

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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Brief summary or purpose:

The Case Manager Triage Nurse for IHCS and PCA Program Management serves as the primary clinical subject matter expert and operational lead for In Home Clinical Services (IHCS) and the Personal Care Attendant (PCA) Program.

This role provides clinical triage, case consultation, program oversight, regulatory guidance, and interdisciplinary collaboration to ensure timely resolution of complex member issues while supporting compliance with state and organizational requirements.

The Triage Nurse functions as the single point of ownership for escalated IHCS and PCA concerns, partnering with Nurse Case Managers, Navigators, LTSS teams, providers, vendors, and community partners to optimize member outcomes, support operational efficiency, identify trends, and drive continuous process improvement.

This role is designed as a hybrid of a Nurse Case Manager, clinical triage specialist, program manager, and operational subject matter expert. The goal is to create single-point ownership for complex IHCS and PCA issues while allowing frontline staff to focus on direct member management.

Primary

Job Responsibilities:

IHCS Clinical Management & Triage

• Serve as the primary clinical liaison between Clinical Integration and IHCS.
• Represent Clinical Integration in IHCS meetings, case conferences, and operational work groups.
• Review and triage complex IHCS referrals, service concerns, provider issues, and care coordination challenges.
• Facilitate interdisciplinary case consultations for members with complex clinical, behavioral, or social needs.
• Coordinate communication and follow-up between IHCS providers, care teams, and leadership.
• Identify service barriers, trends, and systemic issuesimpactingmembers receiving IHCS.
• Develop recommendations to improve service delivery, communication, and member outcomes.
• Monitor IHCS performance, service utilization, and operational effectiveness.

PCA Program Management

• Serve as the organizational subject matter expert for the PCA Program and applicable Mass Health regulations.
• Manage escalated PCA requests, concerns, service disputes, and operational challenges.
• Lead Time-for-Task reviews and support clinical decision-making regarding PCA service needs.
• Review complex PCA assessments and assist staff with interpretation of PCA eligibility guidelines.
• Provide consultation regarding PCA eligibility determination, service authorizations, appeals and denials, program compliance requirements, and EVV-related processes.
• Partner with LTSS,Utilization Management, and Medical Directorsregardingcomplex PCA cases.
• Collaborate with EVV stakeholders toidentifybarriers and develop solutions related to PCA service delivery.
• Monitor…