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Fallon Health Care Coordinator-Case Management-ACO - New Roles - Growing Health Insurance! in Worcester, Massachusetts

Overview

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.

Position Overview:

The Internal Navigator serves on an interdisciplinary team focused on care coordination, care management and improving access to and quality of care for Fallon members. The Internal Navigator supports the Clinical Integration Team in a role that does not routinely complete in home visits. Responsibilities include: phone coverage/triage calls to appropriate team, completing telephonic health risk assessments, uploading documents into TruCare (care management platform), assist the team with identifying gaps in care and follow-up per program protocol (e.g. Key Metrics, Influenza, etc.), assisting the member in scheduling appointments, as appropriate, assisting the team with obtaining medical records and other required documents from the health care providers and ensuring uploading into TruCare, and assisting with letter generation and mailings.

Responsibilities

  • Excellent communication and interpersonal skills with members and providers via telephone

  • Exceptional customer service skills and willingness to assist ensuring timely resolution

  • Excellent organizational skills and ability to multi-task

  • Appreciation and adherence to policy and process requirements

  • Independent learning skills and success with various learning methodologies including but not limited to: self-study, mentoring, classroom, and group education

  • Working with an interdisciplinary care team as a partner demonstrating respect and value for all roles and is a positive contributor within job role scope and duties

  • Willingness to learn about community resources available to assist the member population in the community and long term care settings and demonstrated willingness to seek resources and expand knowledge to assist the population

  • Willingness to learn insurance regulatory and accreditation requirements

  • Familiar with Excel spreadsheets to manage work and exposure and familiarity with pivot tables

  • Accurate and timely data entry

  • Effective care coordination skills and the ability to communicate, advocate, and follow through to ensure member needs are met

  • Knowledgeable regarding community resources

  • Ability to communicate effective to physician and other medical providers

  • Ability to effectively respond and adpt to changing business needs and be an innovative and creative problem solver

Competencies:

  • Demonstrates commitment to the Fallon Health Mission, Values, and Vision

  • Specific competencies essential to this position:

  • Problem Solving

  • Asks good questions

  • Critical thinking skills, looks beyond the obvious

  • Adaptability

  • Handles day to day work challenges confidently

  • Willing and able to adjust to multiple demands, shifting priorities, ambiguity, and rapid change

  • Demonstrates flexibility

  • Written Communication

  • Is able to write clearly and succinctly in a variety of communication settings and style

Qualifications

Minimum of high school diploma required; College Degree (BA/BS) in Health Services field or Social Work) preferred.

License: Current MA Driver’s License   

Certification: None   

Other: Satisfactory Criminal Offender Record Information (CORI) results.

  • 2+ years job experience in a managed care company, medical related field, or community social service agency required

  • Understanding of hospitalization experiences and the impacts and needs after facility discharge required

  • Knowledgeable about medical terminology and basic understanding of common disease processes and conditions required

  • Knowledgeable about medical record documentation and able to recognize triggers requiring RN intervention required

  • Experience with telephonic interviewing skills and working with a diverse population, that may also be Non-English speaking required

  • Understanding of the impacts of social determinants of health required

  • Knowledgeable about software systems including but not limited to Microsoft Office Products – Excel, Outlook, and Word required

  • Experience working in a community social service agency, skilled home health care agency, community agency such as adult foster care, group adult foster care, personal care management agency, independent living agency, State Agency such as the Department of Mental Health (DMH), Department of Developmental Services (DDS), Department of Children and Families (DCF), and/or the Department of Youth Services (DYS), or other agency servicing those in need preferred

  • Experience in a nursing facility or in a Massachusetts Aging Access Service Point Agency preferred

  • Experience working on a multi-disciplinary care team in a managed care organization preferred

AND IF Working with the ACO Member Population:

  • 2+ years of experience working with people up to age 65 with a focus on working with people that are on MassHealth coverage and may be encountering social, economic, and/or multi complex medical and or behavioral health conditions required

  • Effective telephonic interviewing skills and the demonstrated ability to coordinate MassHealth benefits such as transportation through the State PT-1 process preferred

  • IF focused to work with the pregnant member population, 2+ years of experience working with pregnant females during the prenatal, delivery, and postpartum time working in conjunction with RNs coordinating care required

Bilingual skills, fluency in Spanish preferred

Job ID 5736

# Positions 1

Category Case Management

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