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Fallon Health ACO Nurse Case Specialist - Looking for a new career Fallon Health Insurance! 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.

Brief Summary of purpose :

The Case Manager proactively identifies and assesses high-risk members, with complex conditions, and develops and implements an individualized, coordinated care plan, in collaboration with member and primary Care Physician and/or specialist, to ensure a cost effective, quality outcome, focused in the ambulatory setting. The Case Manager assists the member in attaining and/or maintaining an optimal functional status. The Case Manager is responsible for all activities related to:

  • Working directly with members, their physicians, and other care managers to assess the needs of high-risk members and develop customized, proactive care plans resulting in the member attaining and/or maintaining an optimal functional status. Performs medication reconciliations.

  • Authorizing services, coordinating care, ensuring timeliness and coordinating healthcare services, in compliance with documented care plan goals and objectives, and Department and regulatory standards, seeking supplemental benefit and/or community services when appropriate or needed. Refers to and works with Department Social Workers on member specific care plans.

  • Working with the members to assist with learning how to self-manage his or her health needs, social needs or behavioral health 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 Case Manager promotes and works towards achieving the goals and objectives of the Care Services Department and Fallon Health Plan.


  • Effectively manages all outpatient care/case management functions to ensure FH members receive high quality, cost effective an advocacy and a ‘navigator’ role assisting the member to ‘navigate’ the health care system.

  • Screens member enrollment data, claims data, urgent and emergency room utilization, acute inpatient notes, referrals from providers and vendors, and other appropriate data to initiate a member assessment.

  • Verifies member enrollment data, verifying eligibility, benefit plan coverage, and network affiliation.

  • Telephonically contacts members/families/caregivers and:

  • Introduces the member to the program through a telephone call or letter correspondence.

  • Ensures verbal consent of participation is obtained from the member.

  • Conducts screenings and assessments on members that meet the criteria for entry into the Case management Program.

  • Initiates a home visit through contracted home health care vendors for those members in need of an on-site assessment in order to develop a comprehensive care plan.

  • Facilitates the development and implementation of an individualized care plan, in collaboration with the member, Primary Care Physician and specialists if applicable, incorporating assessment, education, resource planning and coordination of services for members accepted into the Case Management program.

  • Communicates with member/family/caregiver(s) in accordance with frequency of Case Management contact guidelines.

  • Incrementally monitors the effectiveness of the care plan with defined, measurable goals and objectives and cost-benefit documentation as applicable and modifies the care plan when applicable.

  • Performs medication review during initial specialty assessment and during other outreach calls as applicable. If unable to do medication review with the member must get list of medications, including dosage and frequency form PCP.

  • Contacts the member’s physician(s) by communicating any medication issues or other clinical issues or needs needing physician awareness and direction. Updates the member/family/caregiver(s) as required.

  • Identifies, aligns, and utilizes health plan and community resources (such as education, support groups, and community providers) that impact high-risk care.

  • Streamlines 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-effectiveness of care.

  • Collaborates with FH Inpatient Clinical Staff to facilitate a safe, timely discharge from the inpatient setting to the next appropriate level of care setting.

  • Creates contingency plans for each step of the process to anticipate treatment and service complications, while ensuring that the member attainspre-determined outcomes.

  • Uses the appropriate FH IT application(s) to document all case activity and facilitate appropriate communication regarding Case Management members.

  • Issues letters according to the Case Management policies and procedures.

  • Initiates case conferences with member/family/caregiver(s) as necessary and coordinates the participation of appropriate interdisciplinary team members.

  • Participates in as needed case conferences with the leadership team and/or Medical Director to discuss patient issues and/or concerns. Organizes and presents complex medical cases in a clear and concise manner both oral and written.

  • Refers appropriate cases to the Medical Director for member 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, problems, goals, interventions, cost/benefit analyses, and other statistics as needed, to demonstrate the clinical quality outcomes and cost-effective financial impact of care management.

  • Identifies and shares best practices and innovative care/case management strategies with the team.

  • Ensures ad hoc contracts are in place for non-contracted services working in conjunction with FH Network Development team.

  • Resolves conflicts among participants in the care planning process

  • Participates in collaborative care initiatives as assigned

  • Supports department colleagues, covering and assuming changes in assignment as assigned by Manager of Case Management, Integrated CM and UM department.

  • Strictly observes HIPPA regulations and the FH policies regarding confidentiality of member information.

  • Performs other responsibilities as assigned by the Manager of Case Management or Senior Director of Integrated Cm and UM.

  • Knowledge of NCQA standards and the ability to meet NCQA documentation and outreach requirements

  • Knowledge of case management Practices, outreach strategies and community resources

  • Understanding of Medicaid, Medicare and commercial Insurance plans

  • Ability to complete transitions of care assesments and medication reconcilliations

  • Diverse clinical experiencce in multiple settings accross all age groups

Demonstrate the following areas of proficiency including, but not limited to:

  • Ability to work with an interdisciplinary care team as a partner, demonstrating respect and value for all roles and serving as a positive contributor within job role scope and duties

  • Robust knowledge of Medicaid programs and the needs of Medicaid populations

  • Able to function independently to establish work plans and priorities

  • Team player, dedicated to the company’s mission and core values, with a track record demonstrating accountability for results

  • Have experience on the clinical and care management of diverse low income populations

  • Collaborate with the ACO Clinical and Operations teams to develop solutions to complex clinical care situations. Participate in interdisciplinary care team discussions at FH to improve operations and overall optimal member care



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


  • RN required - BSN preferred,

  • Active licensure as a Registered Nurse (RN) in Massachusetts,

  • Certification in Case Management (CCM) or Certification in Managed Care Nursing (CMCN) a plus


  • 3-5 years clinical experience as a Registered Nurse managing chronically ill high-risk patients OR as a social worker in a clinical setting

  • Home Health Care experience a plus

  • 1 year experience as a case manager in a managed care setting preferred

  • Excellent (verbal and written) communication and organizational skills.

  • Is willing and able to adjust to multiple demands, shifting priorities, ambiguity and rapid change.

  • Shows resilience in the face of constraints, frustrations, or adversity.

  • Comprehends the difference between a “managed care” philosophy and a “fee-for-service” mentality in a health care delivery system.

  • Familiar with the Case Management Society of America and/or New England’s definition and mission of case management

  • Familiar with NCQA case management requirements

  • Familiarity with provisions of governmental and accrediting agency health plan requirements.

  • Ability to follow the ‘logical’ management of a member’s care throughout the continuum of care.

  • Computer literacy required.

  • Good interpersonal and telephonic assessment skills.

Job ID 5450

# Positions 1

Category Case Management