Aco Nurse Case Manager - Worcester, United States - Fallon Health

Fallon Health

Verified Company

Worcester, United States

3 weeks ago

Posted by:

Mark Lane

beBee recruiter

Description

Overview:

The ACO Nurse Case Manager will be working hybrid remote This position may require working in an Atrius medical office 1 day/week in either Norwood or Quincy and the other days will be able to work from home.

About us:

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

We believe our individual differences, life experiences, knowledge, self-expression, and unique capabilities allow us to better serve our members.

We embrace and encourage differences in age, race, ethnicity, gender identity and expression, physical and mental ability, sexual orientation, socio-economic status, and other characteristics that make people unique.

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 or follow us on Facebook, Twitter and LinkedIn.

Brief summary of purpose:

The Accountable Care Organization (ACO) Nurse Case Manager (NCM) is an integral part on an interdisciplinary team focused on transition of care assessment and support, care coordination, care management and improving access to and quality of care for Fallon Health ACO members.

The NCM embeds in the ACO Partner Provider Offices and works closely with ACO Partner Providers, Office Staff, Care Management Staff and others at the Partner sites managing member care.

NCM seeks to establish telephonic and/or face to face relationships with the member/caregiver(s) to better ensure ongoing service provision and care coordination, consistent with the member specific care plan developed by the NCM and Care Team.

Responsibilities may include conducting in home/office face to face visits for member identified as needing face to face visit interaction and assessments with the goal to coordinate and facilitate services to meet member needs according to benefit structures and available community resources.

The NCM conducts assessments and refers members to Community Partner Programs such as Behavioral Health and Long-Term Services and Supports.

The NCM may also refer members to Flex Program as applicable depending upon the ACO the member is affiliated with.

The NCM may utilize an ACD line to support department and incoming/outgoing calls with the goal of first call resolution with each interaction.

Responsibilities:

Primary Job Responsibilities
Member Assessment, Education, and Advocacy

Telephonically assesses and case manages a member panel
May conduct in home face to face visits for onboarding new enrollees and reassessing members, utilizing a variety of interviewing techniques, including motivational interviewing, and employs culturally sensitive strategies to assess a Member's clinical/functional status to identify ongoing special conditions and develops and implements an individualized, coordinated care plan, in collaboration with the member, the Clinical Integration team, and Primary Care Providers, Specialist and other community partners, to ensure a cost effective quality outcome
Performs medication reconciliations
Performs Care Transitions Assessments per Program and product line processes
Maintains up to date knowledge of Program and product line benefits, Plan Handbook Benefits and 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 objectives
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 selfmanage 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
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