Fallon Health Social Care Manager/ACO 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.
Brief Summary of Purpose:
The SCM provides services to members as referred by FH Care Management team or other referral sources. The SCM assesses member needs, services and resources to address social, health, or economic needs of FH members. The SCM assists the member and or family to provide care utilizing FH benefits and/or community resources. The SCM develops a plan to coordinate a continuum of care consistent with the members’ health care needs and/or goals. The SCM is able to utilize knowledge of benefit plan design, eligibility and/or financing alternatives available within the community to provide options that meet member’s needs.
The SCM is able to identify services, care delivery settings, and funding arrangements that meet the needs of the members. He/She recommends alternatives where appropriate. The SCM monitors care and provides consistent feedback to the team on progress. Works with community based groups to address service gaps and serves as a liaison to social and health resources. The SCM collaborates and works with the Inpatient/Outpatient Nurse Case Managers. The SCM is responsible for all activities related to:
Working directly with members, their physicians, and other care managers to assess the needs of high-risk/high-cost patients and develop customized, proactive care plans resulting in the Member attaining and/or maintaining an optimal functional status.
Ensuring timeliness and coordination of healthcare services in compliance with documented care plan goals and objectives.
Following Department and regulatory standards, seeks supplemental benefit and/or community services when appropriate or needed to meet member’s needs.
Working independently and collaboratively as a facilitator with other members of the health care team to ensure that members receive quality, cost-appropriate care.
In conjunction with both internal and external customers, the SCM promotes and works towards achieving the goals and objectives of the Case Management Department and Fallon Health.
Reviews Member enrollment data, claims data, urgent and emergency room utilization, acute inpatient census, referrals from providers and vendors, and other appropriate data prior to initiating a Member contact.
Telephonically contacts members/families/caregivers and introduces the Member to the Social Care Management Program through a telephone call or letter correspondence.
Conducts a Social Care Management needs assessment on Members and assists them with difficult or complex care delivery or discharge planning needs.
Works with Nurse Case Managers to coordinate a continuum of care for members consistent with the members’ health care goals and needs.
Identifies, aligns, and utilizes health plan and community resources that impact high-risk/high cost care.
Maintains an ongoing awareness of clinical, social, and financial resources available in the community as well as State/Federal and national resources.
Coordinates and works with governmental, private, civic, religious, business and/or other groups to arranges and coordinate plans for members served in the Program.
Assists members/caregivers to apply for community services and funding arrangements as necessary.
Assists members in establishing or reinforcing a social support network, thereby reducing their dependence on the medical system.
Initiates a home visit for those Members in need of an on-site assessment in order to develop a comprehensive care plan.
Communicates regularly with member and/or caregivers in accordance with frequency of Contact Guidelines.
Incrementally monitors the effectiveness of the care plan with defined, measurable goals and objectives and cost-benefit documentation.
Initiates case conferences with Member/family/caregiver(s) as necessary and coordinates the participation of appropriate interdisciplinary team members.
Involved in meetings, as appropriate, with the interdisciplinary team, Primary Care Physician, and other participating personnel to update all relevant team members regarding the patient’s status and the need for any modifications to the care plan.
Assesses the health and emotional needs of the members being served.
Organizes and presents complex medical cases in a clear and concise manner both verbally and written.
Refers appropriate cases to the physician advisor and/or Medical Director for patient conference with the PCP regarding care issues (e.g. treatment modality, appropriate utilization of services, quality/risk issues).
Maintains documentation of individual care management plans, interventions, cost/benefit analyses, and other statistics as needed, to demonstrate the clinical quality outcomes and cost-effective financial impact of care management.
Uses the appropriate FH IT application(s) to document all case activity and facilitate appropriate communication between Case Management team members.
Identifies and shares best practices and innovative care management strategies with the team.
Resolves conflicts among participants in the care planning process.
Issues letters per departmental policy and procedure.
Collaborates with FH Inpatient Case Managers to facilitate a safe, timely discharge from the inpatient setting for members enrolled in the Case Management Programs .
Master’s degree from an accredited school of social work, mental health counseling, psychology, or human services required.
Licensed or licensed eligible if applicable. Certification in Case Management desired.
Three to four years of experience working with the following: the chronically ill, SPMI, and substance use populations.
Background working with all age groups preferred.
Experience working in a healthcare setting as a member of a professional clinical team required.
Previous experience working at an MCO strongly preferred.
Experience and comfort conducting face-to-face visits with membership in the community and in their homes.
Job ID 5449
# Positions 1
Category Case Management