Nurse Case Manager - Senior Care Options - Lakeville

apartment Fallon Health location_onLakeville, MA 02347, US

Overview

The Nurse Case Manager is covering Lakeville, Acushnet, Fairhaven, Rochester and Mattapoisett and surrounding territory.

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 Nurse Case Manager (NCM) is an integral part on an interdisciplinary team focused on care coordination, care management and improving access to and quality of care for Fallon members. 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 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 may conduct assessments and may determine the number of hours’ members require for MassHealth programs such as the personal care attendant program, adult foster care, group adult foster care, and other programs per product benefits and guidelines. 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

Note: Job Responsibilities may vary depending upon the member’s Fallon Health Product

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

Utilizing clinical judgment and nursing assessment skills, may complete NaviCare Program Assessment Tools and Minimum Data Set Home Care (MDS HC) Form when a member’s medical/functional status changes that warrants a change in rating category to ensure members are in the correct State defined rating category

Maintains up to date knowledge of Program and product line benefits, Plan Evidence of 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 self- manage 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

Educate members on preventative screenings and other health care procedures such as vaccines, screenings according to established protocols and program processes such initiatives involving Key Metrics outreach

Ensures members/PRAs participate in the development and approval of their care plans in conjunction with the interdisciplinary primary care team

Strictly observes HIPAA regulations and the Fallon Health Policies regarding confidentiality of member information

Supports Quality and Ad-Hoc campaigns

Care Coordination and Collaboration

Provides culturally appropriate care coordination, i.e. works with interpreters, provides communication approved

documents in the appropriate language, and demonstrates culturally appropriate behavior when working with member, family, caregivers, and/or authorized representatives

With member/authorized representative(s) collaboration develops member centered care plans by identifying member care needs while completing program assessments and working with the Navigator to ensure the member approves their care plan

Manages NaviCare members in conjunction with the Navigator, Behavioral Health Case Manager, Aging Service Access Point Geriatric Support Service Coordinator, contracted Primary Care Providers and others involved/authorized in the member’s care

Manages ACO members in conjunction with the Navigator, Social Care Managers, ACO Partners, Community Partners, Behavioral Health Partners and others involved/authorized in the member’s care

Monitors progression of member goals and care plan goals, provides feedback and works collaboratively with care team members and work effectively in a team model approach to coordinate a continuum of care consistent with the Member’s health care goals and needs

Works collaboratively with Fallon Health Pharmacist, referring members in need of medication review based upon Program process

Develops and fosters relationships with members, family, caregivers, PRAs, vendors and providers to ensure good collaboration and coordination by streamlining 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

Actively participates in clinical rounds

Provider Partnerships and Collaboration

May attend in person care plan meetings with providers and office staff and may lead care plan review with providers and care team as applicable.

Demonstrates positive customer service actions and takes responsibility to ensure member and provider requests and needs are met

Regulatory Requirements – Actions and Oversight

Completes Program Assessments, Notes, Screenings, and Care Plans in the Centralized Enrollee Record according to product regulatory requirements and Program policies and processes

Knowledge of and compliance with HEDIS and Medicare 5 Star measure processes, performing member education, outreach, and actions in conjunction with the Navigator and other members of the Clinical Integration and Partner Teams

Performs other responsibilities as assigned by the Manager/designee

Supports department colleagues, covering and assuming changes in assignment as assigned by Manager/designee

Qualifications

Education:

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

License:

Active, unrestricted license as a Registered Nurse in Massachusetts

Certification:

Certification in Case Management strongly desired

Other:

Satisfactory Criminal Offender Record Information (CORI) results and reliable transportation

Experience:

• 1+ years of clinical experience as a Registered Nurse managing chronically ill members or experience in a coordinated care program required• Understanding of Hospitalization experiences and the impacts and needs after facility discharge required• Experience working face to face with members and providers preferred• Experience with telephonic interviewing skills and working with a diverse population, that may also be Non-English speaking, required• Home Health Care experience preferred• Effective case management and care coordination skills and the ability to assess a member’s activities of daily function and independent activities of daily function and the ability to develop and implement a care plan that meets the member’s need working in partnership with a care team preferred• Familiarity with NCQA case management requirements preferred

Performance Requirements including but not limited to:• Excellent communication and interpersonal skills with members and providers via telephone and in person• Exceptional customer service skills and willingness to assist ensuring timely resolution• Excellent organizational skills and ability to multi-task• Appreciation and adherence to policy and process requirements• Independent learning skills and success with various learning methodologies including but not limited to: self-study, mentoring, classroom, and group education• Working with an interdisciplinary care team as a partner demonstrating respect and value for all roles and is a positive contributor within job role scope and duties• Willingness to learn insurance regulatory and accreditation requirements• Knowledgeable about software systems including but not limited to Microsoft Office Products – Excel, Outlook, and Word • Familiar with Excel spreadsheets to manage work and exposure and familiarity with pivot tables• Accurate and timely data entry• Effective case management and care coordination skills and the ability to assess a member’s activities of daily function and independent activities of daily function and the ability to develop and implement a care plan that meets the member’s need • Knowledge about community resources, levels of care, criteria for levels of care and the ability to appropriately develop and implement a care plan following regulatory guidelines and level of care criteria • Ability to effectively respond and adapt to changing business needs and be an innovative and creative problem solver

Competencies:

• Demonstrates commitment to the Fallon Health Mission, Values, and Vision• Specific competencies essential to this position:

Problem Solving
- Asks good questions
- Critical thinking skills; looks beyond the obvious
Adaptability
- Handles day to day work challenges confidently
- Willing and able to adjust to multiple demands, shifing priorities, ambiguity, and rapid change
- Demonstrates flexibility
Written Communication
- Is able to write clearly and succinctly in a variety of communication settings and styles.

Pay Range Disclosure:

In accordance with the Massachusetts Wage Transparency Act, the pay range for this position is $88,000 - $95,000 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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Core Competencies: Demonstrates empathy and compassion with all interactions with residents and with families Articulates importance of supporting independence and resident choice when caring for residents Demonstrates strong communication skills and ability to foster teamwork Articulates commitment to excellence and high quality care Articulates the importance of accountability and personal ownership related to teamwork and resident care Demonstrates strong critical thinking skills Demonstrates ability to coach and mentor others to achieve high quality care Position Responsibilities: Ensures all care delivered is within the scope and established standards of safe professional nursing practice and HSL core competencies Collaborates with other members of the clinical support team (MD, NP, nurses, social worker, therapists, dietician) to meet the clinical needs of the resident and monitor outcomes of care Adheres to best practice recommendations and implements evidence based interventions to ensure optimum outcomes for residents Practices in a primary nursing model and maintains accountability for a set of assigned residents/patients Collaborates and participates in care planning activities and supports autonomy and individual choice wherever possible Ensures adherence to the plan of care, revises as necessary, and ensures the plan accurately reflects an individualized approach to resident’s needs Documents appropriately in the electronic medical record Identifies and seeks out necessary resources as needed to ensure the provision of safe and effective care Delegates and supervises clinical care delivered by the licensed practical nurse and the nursing assistant Assumes accountability for his/her own learning needs and professional development Demonstrates critical thinking abilities in problem resolution Role models professional behavior Actively participates in shared governance, committees, etc Collaborates in the development of new work processes and systems Serves as a resource and support to the elder assistants in the households Identifies and responds to safety concerns on the household and neighborhood Maintains compliance with policies, procedures, practice and regulatory matters Participates in the collection and monitoring of quality data to ensure high standards of care Participates in performance improvement projects Participate and assists with activities (i.e. assist with serving meals) Serves as a coach and mentor to all staff, i.e. Nursing/Resident assistants and LPNs May be assigned charge nurse responsibilities. Responsibilities may include: Giving shift report to on coming staff Provide clinical/supervisory oversight to assigned unit during shift Delegate assignments to team assigned to shift Initiate necessary reports including DPH, incident reports, concern resolutions Assure completion of admission or discharges during shift Attend rounds (wound, physician etc) Provides oversight of LPN assessments (as assigned) and co-signs nursing assessments and initial care plans The above covers the most significant responsibilities of the position. It does not, however, exclude other duties, which would be in conformity with the level of the position. Completes special projects as assigned Qualifications: Graduate of approved school of nursing required; BSN preferred Current Massachusetts license as an R.N. in good standing Previous experience preferred Understand the philosophy and support the model of care at HRC required Must be professional, proactive, collaborative, conscientious and results-oriented individual. Must have an optimistic and positive demeanor, excellent oral and written communication skills, good intuition and able to adapt to changing priorities and display good, sound judgment with a sense of humor Superb organizational skills. Must have solid analytical skills. Must be creative and proactive yet disciplined, discriminating and able to streamline work volume in order to maintain bottom line efforts in midst of multi-tasking and daily re-prioritizing. Must have ability to innovate, think strategically and conceptually, manage multiple projects simultaneously and handle even difficult situations Must be motivated to learn and flexible to change Computer literacy required Excellent English language skills, written and verbal Pass Med test with 80% or greater Working Conditions and Physical Demands: Contact with residents under a wide variety of circumstances, which may include exposure to unpleasant odors, sights, and sounds Push occupied wheel chairs on flat surfaces, and up/down ramp up to 50 lbs Standing, walking, and sitting Lifting supplies and equipment up to 50 lbs Some reaching, stooping, squatting, bending, kneeling and crouching Remote Type On-site Hebrew SeniorLife is an equal opportunity employer. We celebrate diversity and are committed to creating an inclusive environment for all employees.