Job Description

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, we deliver equitable, high-quality coordinated care and are continually rated among the nation’s top health plans for member experience, service, and clinical quality.

Fallon Health’s Summit ElderCare® is a Program of All-Inclusive Care for the Elderly–PACE for short. PACE, an alternative to nursing home care, is a program that helps people 55 and older continue living safely at home. At Fallon Health, 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— in the region.

Brief summary of purpose

Provides coordination, scheduling and problem resolution for all approved home care services for SE participants. Documents all actions in a timely manner in an electronic medical record (EMR). Supports other program administration needs as assigned.

Responsibilities

Primary Job Responsibilities

• Coordinates and schedules home care services to implement the plan of care established by the interdisciplinary team (IDT).   
• Works collaboratively with Home Care nurses and other staff, vendors, participants and families to support SE’s mission, promote high quality care and service as well as positive internal and external customer relations.   
• Communicates with homecare agencies and other vendors to coordinate services including initial orders, changes, cancellations and resumption of services.  
• Demonstrates professionalism and acts as an ambassador for Fallon Health and Summit ElderCare at all times 
• Emails or faxes open case needs to homecare agencies as required. 
• Effectively utilizes established systems and procedures to identify problem cases and alert management of need for additional interventions.    
• Follows up on all non-assigned cases as required until services are secured.    
• Documents all vendor authorizations and service coordination efforts in the EMR and other identified systems as assigned.
• Documents all participant related telephone calls in the EMR.  
• Faciliates timely delivery of service authorizations to vendors.  
• Maintains a positive working relationship with peers, vendors and other staff.     
• Maintains an accurate record of participants’ home care services in a designated format.
• Utilizes established systems to track data as assigned. Prepares reports as requested.
• Conducts periodic audits of claims paid to ensure services were authorized by the IDT and facilitates resolution of identified issues.
• Is expected to be a part of the weekend on call rotation.
• Performs photocopying, faxing and other clerical duties as required.
• Performs other duties as assigned by Operations Manager and other leadership staff.

Qualifications

Qualification requirements

Education

• High School diploma or equivalent preferred, or substantial work experience.

License/Certification

n/a

Experience

• Past home care coordination experience highly desirable. Previous customer service experience preferred.
• Excellent telephone and customer service skills
• Relationship building skills
• Strong organizational skills
• Strong work ethic
• Strong basic computer and office skills specifically with Microsoft Office
• Ability to plan work and meet required deadlines
• Ability to work in a fast-paced environment
• Basic math skills
• Ability to learn insurance terminology related to authorizations, claims and payments
• Ability to perform multiple tasks efficiently and accurately, to proactively identify problems and resolve issues with minimal supervision.

Pay Range Disclosure:

• In accordance with the Massachusetts Wage Transparency Act, the pay for this position is budgeted for $23.20 per hour 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.#P02