Overview
The ACO Nurse Case Manager will be working hybrid remote! This position may require working in an Atrius medical office 1 day/week in either Norwood or Quincy and the other days will be able to work from home.
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. Learn more at fallonhealth.org or follow us on Facebook, Twitter and LinkedIn.
The Accountable Care Organization (ACO) Nurse Case Manager (NCM) is an integral part on an interdisciplinary team focused on transition of care assessment and support, care coordination, care management and improving access to and quality of care for Fallon Health ACO members.
Responsibilities
Member Assessment, Education, and Advocacy
- 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 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 Clinical Integration team, and Primary Care Providers, Specialist and other community partners, to ensure a cost effective quality outcome
- Performs medication reconciliations
- Performs Care Transitions Assessments - per Program and product line processes
- Maintains up to date knowledge of Program and product line benefits, Plan Handbook Benefits and 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 coordinate healthcare services ensuring timeliness in compliance with documented care plan goals and objectives
- Assesses the Member's knowledge about the management of current disease processes and medication regimen, provides teaching to increase Member/caregiver knowledge, and works with the members to assist with learning how to self-manage his or her health needs, social needs or behavioral health needs
- Collaborates with appropriate team members to ensure health education/disease management information is provided as identified
- Collaborates with the interdisciplinary team in identifying and addressing high risk members
- Educate members on preventative screenings and other health care procedures such as vaccines, screenings according to established protocols and program processes
- Ensures members/PRAs participate in the development and approval of their care plans in conjunction with the interdisciplinary primary care team
- Strictly observes HIPAA regulations and the Fallon Health Policies regarding confidentiality of member information
- Supports Quality and Ad-Hoc campaigns
Care Coordination and Collaboration
- Provides culturally appropriate care coordination, i.e., works with interpreters, provides communication approved documents in the appropriate language, and demonstrates culturally appropriate behavior when working with member, family, caregivers, and/or authorized representatives
- With member/authorized representative(s) collaboration develops member centered care plans by identifying member care needs while completing program assessments and working with the member to approve their care plan
- Manages ACO members in conjunction with the Navigator, Social Care Managers, ACO Partners, Community Partners, Behavioral Health Partners and others involved/authorized in the member's care
- Monitors progression of member goals and care plan goals, provides feedback and works collaboratively with care team members and work effectively in a team model approach to coordinate a continuum of care consistent with the Member's health care goals and needs
- Works collaboratively with Fallon Health Pharmacist, referring members in need of medication review based upon Program process
- Develops and fosters relationships with members, family, caregivers, PRAs, vendors and providers to ensure good collaboration and coordination by streamlining the focus of the Member's healthcare needs utilizing the most optimal treatment approach, promoting timely provision of care, enhancing quality of life, and promoting cost-effectiveness of care
- Actively participates in clinical rounds
Provider Partnerships and Collaboration
- May attend in person member/provider visits, care plan meetings with providers and office staff and may lead care plan review with providers and care team as applicable
- Demonstrates positive customer service actions and takes responsibility to ensure member and provider requests and needs are met
Regulatory Requirements - Actions and Oversight
- Completes Program Assessments, Notes, Screenings, and Care Plans in the TruCare and Provider EMR systems according to Program policies and processes
Qualifications
Education
Graduate from an accredited school of nursing mandatory and a Bachelors (or advanced) degree in nursing or a health care related field preferred.
License/Certifications
License: Active, unrestricted license as a Registered Nurse in Massachusetts; current Driver's license and reliable transportation
Certification: Certifi