RN Case Manager - ACO - Berkshire County - New Role - Growing Healthcare Organization - Fallon Community Health Plan
Fallon Community Health Plan
: $89,330.00 - $131,710.00 /year *
: Healthcare - Nursing
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RN Case Manager - ACO - Berkshire County - New Role - Growing Healthcare Organization
Job ID: 5598 Type: Full Time # of Openings: 1 Category: Nursing Recruiting Location - Berkshire, MA
About Fallon Health
Founded in 1977, Fallon Health is a leading health care services organization that supports the diverse and changing needs of those we serve. In addition to offering innovative health insurance solutions and a variety of Medicaid and Medicare products, we excel in creating unique health care programs and services that provide coordinated, integrated care for seniors and individuals with complex health needs. Fallon has consistently ranked among the nation's top health plans, and is accredited by the National Committee for Quality Assurance for its HMO, Medicare Advantage and Medicaid products. For more information, visit fallonhealth.org.
Brief Summary of Purpose:
This role is responsible for the Berkshire County area and will act as the Liaison between Fallon Health the ACO and our member, you need to be very flexible and a relationship builder.
The ACO Liaison Nurse Case Manager (NCM) works closely with Fallon Health's ACO and Community Partners at their sites to support, educate,
develop and maintain positive relationships with members, caregivers, medical professionals in the communities we serve. Through the building of
long term relationships, the Liaison will facilitate communication and care coordination between all ACO Partners, thus improving quality of care and access to services for Fallon ACO members. The Liaison NCM will work in collaboration with the ACOs and Community Partners to support the members in a role that may include completing in-home/facility face to face visits with members and/or providers. Responsibilities include: telephonically assessing a Member's clinical/functional status to identify ongoing special conditions and providing education. Develops and implements a coordinated plan in collaboration with the member, ACO, Community Partners and Primary Care Provider and/or specialist and other community partners to ensure quality outcomes in a cost effective way. Facilitates referrals to Clinical Integration RN team for further member follow-up and/or follow-up with the Care Teams at the ACO and/or Community Partners. Works collaboratively with other members of the Clinical Integration Team.
Provider Partnerships and Collaboration
Partners with Outreach/Provider Relations/Clinical Integration Team Clinical Leadership Team to attend and contributes to Model of Care trainings/orientations with providers and/or vendors explaining the various roles of the clinical team in coordination of member's care
Embeds/Attends and contributes to Model of Care trainings/orientations with providers and/or vendors explaining the various roles of the clinical team in coordination of member's care
Performs and lead in-person member care plan review with providers including but not limited to Primary Care Providers, Aging Service Access Point Providers, Long Term Services and Support Providers, Behavioral Health Providers, Long Term Care Facility Providers, and/or any other Provider/Member/Authorized Representatives to ensure effective communication and collaboration between all involved
Partners with interdepartmental teams (including but not limited to: Utilization Management, Appeals and Grievance, Clinical Integration Team Operations, Provider Relations, Pharmacy, Behavioral Health Leadership) within Fallon Health to ensure provider/member satisfaction is maintained while articulating issues to help to facilitate problem/issue resolution
Regulatory Requirements Actions and Oversight
Works collaboratively with the Manager to ensure program regulatory deadlines are met
Completes Program Assessments, Minimum Data Set Home Care (MDS HC) Assessments, Transition of Care Assessments, and Care Plans in the Centralized Enrollee Record and Virtual Gateway according to Regulatory Requirements and Program policies and processes
Knowledge of and compliance with HEDIS and Medicare 5 Star measure processes, performing member education, outreach, and actions in conjunction with the Navigator
Member Assessment, Education, and Advocacy
Conducts in home face to face visits for Complex Members utilizing a variety of interviewing techniques, including motivational
interviewing, and employs culturally sensitive strategies to assess a Members clinical/functional status to identify ongoing special conditions
Develops and implements an individualized, coordinated care plan, in collaboration with the member and Primary Care Physician and/or specialist, to ensure a cost effective, quality outcome, focused in the ambulatory setting
Performs medication reconciliations
Performs Care Transitions Assessments per Program Processes
Utilizing clinical judgment and nursing assessment skills, completes the Program Assessment Tools
Maintains up to date knowledge of Program 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
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
Graduate from an accrdited school of nursing mandatory and a Bachelors or Advanced degree in nursing or a health care related field preferred.
Active, unrestricted license as a Registered Nurse in Massachusetts; current Driver's license and a vehicle to be used for home visits
Certification in Case Management strongly desired
4+ years of clinical experience as a Registered Nurse managing chronically ill members or experience in a coordinated care program required
2+ years as a Nurse Case Manager with experience teaching and mentoring team members. A willingness to perform unanticipated projects as requested and perform responsibilities as required.
Home Health Care experience preferred
Familiar with NCQA case management preferred
Experience working face to face with members and providers required
Experience with telephonic interviewing skills and working with a diverse population, that may also be Non-English speaking, required
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* The salary listed in the header is an estimate based on salary data for similar jobs in the same area. Salary or compensation data found in the job description is accurate.