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Fallon Health RN Case Manager ACO - New Role - Transition of Care - Growing Healthcare Organization in Worcester, Massachusetts


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.

The ACO Transition of Care Nurse Case Manager (NCM) is focused on care coordination and improving quality of care and access to services for Fallon ACO members at time of care transition – i.e. after hospital, emergency room, skilled nursing facility discharge to home. The 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.

* This role is based in Worcester MA*


Member Assessment, Education, and Advocacy.

  • Completes telephonic assessmentsutilizing 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 Provider and/or specialist and other community partners

  • 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 members benefit package

  • 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 such initiatives involving Key Metrics outreach

  • 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 Navigator to ensure the member approves their care plan

  • 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-effective care

  • Actively participates in internal clinical rounds

  • Regulatory Requirements – Actions and Oversight

  • 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 NCQA, HEDIS and Medicare 5 Star measure processes, performing member education, outreach, and actions in conjunction with the Navigator.

  • Performs other responsibilities as assigned by the Manager/designee.

  • Supports department colleagues, covering and assuming changes in assignment as assigned by Manager/Designee.


Graduate from an accredited school of Nursing mandatory and a Bachelors (or advanced) degree in nursing or a health care related field

L icense: Active, unrestricted license as a Registered Nurse in Massachusetts & current Driver’s license and a vehicle to be used for home visits

Certification : Certification in Case Management strongly desired

Other: Satisfactory Criminal Offender Record Information (CORI) results

Job ID 5600

# Positions 1

Category Nursing