Job Description

Overview

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 fallonhealth.org or follow us on Facebook, Twitter and LinkedIn.

Brief summary of purpose:

The RN Nurse Case Manager (NCM) is an integral part of an interdisciplinary team focused on care coordination, care management and improving access to and quality of care for NaviCare members. The NCM seeks to establish face-to-face and telephonic 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-house face-to-face visits for members identified as needing face-to-face visit interaction and care planning with the goal of coordinating and facilitating services to meet member needs according to benefit structures and available community resources. NCMs are responsible for completing all Transition of Care Assessments, which may be done both in person and telephonically. The NCM is responsible for reconciling all medications at time of transition. The NCM creates all initial care plans, updates care plans as needed and executes care planning activities for medically complex members. The NCM collaborates with Navigators on the care of all members to address medical concerns and to provide holistic and comprehensive case management.

Responsibilities

Primary Job Responsibilities

Member Assessment, Education, and Advocacy

• Assess and manage a member panel through in-person and telephonic outreach.
• Complete medication reconciliations and care transition assessments.
• Educate members on benefits, rights, disease management, medications, and preventive screenings. Ensure members and authorized representatives participate in and approve care plans.
• Support member self-management through coaching and health education.

Care Coordination and Collaboration

• Develop and update individualized care plans based on assessments.
• Coordinate services and authorize care according to program and regulatory standards.
• Collaborate with Navigators, PCPs, Behavioral Health Case Managers, pharmacists, and community partners.
• Track progress toward goals and adjust care plans as needed.
• Participate in interdisciplinary rounds and team communication.
• Build strong relationships with members, caregivers, and providers for coordinated, culturally appropriate care.
• Regulatory Requirements – Actions and Oversight
• Complete assessments, screenings, notes, and care plans within regulatory timelines.
• Follow HIPAA and organizational confidentiality policies.
• Support HEDIS, Medicare 5-Star, and quality initiatives through outreach and education.
• Assist with departmental campaigns, projects, and coverage as assigned.

Qualifications

Education

RNs: Graduate from an accredited school of nursing, associate’s degree required, bachelor’s or higher preferred

License/Certifications

License: RN Candidates (Required) Active, unrestricted license as a Registered Nurse in Massachusetts

Certification: Certification in Case Management strongly desired, willingness to obtain when eligible

Other: Driving your personal motor vehicle is an essential job function for this position and the following requirements apply:

• Must possess a valid drivers’ license
• Must attest to no disqualifiers per Driver Safety Policy
• Must possess and provide proof of minimal state required auto insurance
• Must have reliable transportation

Experience

• 1+ years of clinical RN experience with complex medical, behavioral, and social co-morbidities.
• Ability to conduct assessments in-person and telehealth.
• Ability to work on interdisciplinary teams.
• Skill in screening social determinants of health.
• Strong communication and interviewing skills. Problem-solving skills and adaptability.
• Knowledge or willingness to learn regulatory requirements.
• Preferred experience: Home Health, OASIS/MDS, Medicare/Medicaid, face-to-face member interactions.
• Reliable home internet.

Pay Range Disclosure:

In accordance with the Massachusetts Wage Transparency Act, the pay range for this position is around $95,000 - $100,000 per year, which reflects what we reasonably and in good faith expect to pay at the time of posting. Final compensation will depend on the candidate’s experience, skills, and fit with the role’s responsibilities.

Fallon Health provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.

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