Fallon Medical Jobs

mobile fallon logo

Job Information

Fallon Health RN - Transition of Care Nurse - Elder Service Program (PACE) ! in Amherst, NY, New York


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 www.fallonhealth.org .

About Fallon Health Weinberg - PACE:

Fallon Health Weinberg-PACE is a long-term care program for older adults who need a nursing home level of care, but wish to stay living at home and in their community. We are a Program of All-inclusive Care for the Elderly (PACE), providing complete medical care and support services so you or your loved one can remain living safely at home. All care is coordinated and provided by an interdisciplinary team specializing in geriatric care, who work with participants and their caregivers to create an individualized care plan.


Evaluates and assesses prospective PACE enrollees provided by the outreach. Confirms that prospective enrollee’s meet the eligibility requirements for the PACE program through utilization of the NYS assessment tool (UAS), and presents information to the Interdisciplinary Team in an accurate and concise manner. Keeps the team informed of issues that affect enrollment decisions and maintains data.

Ensures that participants’ transitions of care to and from inpatient facilities are appropriate, timely, and successful. The TCC nurse participates on the Utilization committee to help achieve program business goals.


Primary Job Responsibilities:

  • Attends IDT meetings to discuss inpatients, barriers to discharge or transition, and suggest discharge plans

  • Uses a checklist to ensure that the components of a safe transition of care occurs

  • Visits participants at inpatient facilities as needed to be up to date with their functional and medical status and rehabilitation needs

  • Talks daily with primary team members to address potential barriers to discharge or transition to lesser care setting

  • Recognizes, identifies, and implements appropriate opportunities to help meet Utilization goals

  • Knowledge of managed care, quality, and risk management principles

  • Participates in the Utilization Committee

  • Documents all inpatient care transitions and case management progress notes within the electronic health record

  • Attends family meetings as needed

  • Completes the UAS, estimates whether individual meets clinical criteria for enrollment, and enters MDS state system.

  • Communicates with the Interdisciplinary Team to provide information for enrollment decisions and provides ongoing communication with referral sources, potential enrollees/families during the intake process.

  • Coordinates and communicates necessary information about potential enrollees to the Site Director on an ongoing basis.

  • Assist with completion of UAS assessments annually


Education, License, Certifications, and Experience:

  • Bachelor of Science in Nursing

  • Reliable transportation required

  • Two years nursing experience with at least one year of experience working with a frail or elderly population. Experience in or with long term care facilities and experience with home care desired. Knowledge of Utilization Management principles. Experience with UAS 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 (4/6/2022 4:05 PM)

Job ID 6806

# Positions 1

Category Nursing