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Fallon Health Manager, FHW Clinical Services - Growing MLTC - Great Benefits in Amherst, NY, New York


About Fallon Health:

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 delivers equitable, high-quality coordinated care and is continually rated among the nation’s top health plans for member experience, service, and clinical quality. 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.

About Fallon Health Weinberg-MLTC:

Fallon Health Weinberg-MLTC is a partnership between Fallon Health of Massachusetts and Weinberg Campus of Erie County, New York. Fallon Health Weinberg a Managed Long Term Care (MLTC) is a plan to serve the health needs of dual-eligible residents of the Western New York counties of Erie and Niagara. Fallon Health Weinberg expands the choices that residents of Erie and Niagara Counties have when it comes to high quality, affordable health care.

Brief Summary of Purpose:

The Manager FHW Clinical Services is responsible for:

  • Managing a multi-location clinical team to ensure timely coordination of quality healthcare and care coordination services for Fallon Health members with varying levels of conditions

  • Providing leadership, supervision, and support for direct report clinical and disease management staff fostering integration within care teams and member care plans

  • Collaboratively working with leaders to implement Models of Care, Programs as outlined in Program Descriptions for various Fallon Health products ensuring adherence to CMS, State and other required elements

  • Assisting the Director of Clinical Services (DCS) to ensure that the Fallon Health members have an effective and compliant care plan to meet the member care needs according to product requirements working with clinical staff and leaders to ensure compliance and effectiveness of care plan

  • Assisting the DCS to ensure that the team performance goals are met and ensuring program staff are trained and compliant with departmental and policy requirements

  • Assisting the DCS with educating direct reports on various levels of care coordination/case management interventions and recommending and supporting team actions to ensure effective member care plan development and implementation.

  • Assisting the DCS with Implementation of quality improvement projects and strategies to support the Program in meeting quality and performance measures.

  • Participating in the preparation of member cases files for auditors, regulators, and others as required

  • Partnering and participating in relationships with State Agencies, Provider groups, and other vendors and providers fostering collaborative working relationships

  • Works with DCS to recommend changes to the case management system platform structures in conjunction with division leaders, Fallon Health I.T. and recommends modifications for workflow efficiencies and reporting enhancements based upon team experiences


Job Responsibilities:

Team Management:

  • Hires, orients, trains, supervises, evaluates, counsels, and manages performance staff who function within the assigned Team in conjunction with the DCS

  • Manages time off requests and on-call rotation schedule

  • Provides education to the Team on the various Fallon Health Products, various Models of Care, policies, processes, workflows, and best practices to support member care and Team processes

  • Oversees performance of Team ensuring Program and Team goals are met utilizing reports and facilitating team independent use of such

  • Establishes Team member productivity and professional goals in conjunction with the DCS

  • Evaluates staff performance based on these defined goals and implements coaching and performance improvement measures and actions when necessary in conjunction with the DCS

  • Develops workflows and educates Team on workflows as appropriate

  • Monitors Team adherence to established workflows and implements improvements and workflow modifications as required

  • Meets 1:1 with Direct Reports and reviews established reports and systems to track and ensure performance to Team member and Program goals

  • Works with DCS and/or QA nurse to audit Team member documentation for accuracy, timeliness, appropriateness, and adherence to workflow and works with staff to implement corrective action as warranted

  • Ensures staff utilize an effective communication style and methods to engage members/personal representatives in care management

  • Facilitates and/or co-leads Team huddles as needed – Team huddle content includes but is not limited to Fallon Health member review and brainstorming to meet care plan needs; process development and enhancement; implementation of new duties and tasks; reassignment of work to meet department needs and involvement of LPN Navigator, Social Worker and RN Case Manager resources as appropriate

  • Works with DCS to ensure department team members work collaboratively, shifting workloads and duties to meet Team needs

  • In conjunction with the DCS, recommends, develops, and may work with TruCare I.T. Development team to ensure case management documentation system effective to meet Program needs

  • Carries an Active Member Case load of approximately 25% of agency’s full case load expectation. Case load requirement may increase based on the need of the organization.

  • Performs RN Enrollment responsibilities when needed to support Intake/Enrollment census goals.

Program Leadership Activities – Quality Improvement Focus (as assigned):

  • Participates in, and implements quality improvement projects

  • Ensures team members follow workflow and reporting requirements to support projects and outcome requirements of programs

  • Generates and or utilizes reports to ensure Team performance to goal

  • Utilizes reporting software to generate process measure reports for team performance oversight and teaches team members to be proficient utilizing reporting software to produce their own reports


  • Works collaboratively and cohesively with all members of the care team (both internal and external staff and providers)

  • Maintains an ongoing awareness of clinical, social, and financial resources available in the community

  • Supports department colleagues, covering and assuming changes in assignment as assigned by DCS/designee

  • Strictly observes HIPAA regulations and the Fallon Health policies regarding confidentiality of member information

  • Performs other responsibilities as assigned by the DCS/designee



Graduate from an accredited school of nursing mandatory.

Bachelors (or advanced) degree in nursing or a health care related field preferred


Active, unrestricted license as a Registered Nurse in New York State

Current New York State driver’s license; Certification in Case Management desired.


Satisfactory Criminal Offender Record Information (CORI) results

reliable transportation


  • A minimum of two years’ clinical experience as a licensed Registered Nurse managing/coordinating/facilitating/providing care for member populations required

  • Experience working in a healthcare setting as a member of a professional team coordinating care for adult populations who are diagnosed with health conditions or chronic disease, including mental illness or substance abuse disorders required

  • Familiarity with in-home services both skilled and non-skilled, outpatient services including medical and behavioral health, knowledge of different levels of care including but not limited to acute, rehab, long term, and experience with Medicaid coverage criteria and requirements required

  • One year of supervisory or management experience in a health care setting; preferably with experience supervising/managing staff preferred

  • Two years’ experience performing care coordination in a managed care setting preferred

  • Experience developing policies, procedures, and workflows preferred

  • Experience with performance improvement projects including but not limited to establishing criteria for report queries, utilizing objective data to improve processes, and implementation of projects preferred

Fallon Health Vaccination Requirements:

To protect the health and safety of our workforce, members and communities we serve, Fallon Health now requires all employees to disclose COVID-19 vaccination status. As of 2/1/2022 all roles not designated as “Remote” require full COVID-19 vaccination and Fallon Health will obtain the necessary information from candidates prior to employment to ensure compliance. Failure to meet the vaccination requirement may result in rescission of an employment offer or termination of employment.

Fallon Health provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.

Location US-NY-Amherst, NY

Posted Date 4 months ago (10/20/2022 10:52 AM)

Job ID 7073

# Positions 1

Category Nursing