This company is committed to hiring Veterans

RN Case Manager - Growing Health Care Org!

This job is no longer active. View similar jobs.

POST DATE 8/31/2016
END DATE 10/18/2016

Fallon Health Worcester, MA

Worcester, MA
AJE Ref #
Job Classification
Full Time
Job Type
Company Ref #
Mid-Career (2 - 15 years)
Bachelors Degree



Primary Job Responsibilities:

* Reviews Enrollee enrollment data, claims data, urgent and emergency room utilization, acute/skilled nursing inpatient census, referrals from Primary Care Team (PCT) and vendors, and other appropriate data prior to initiating any Enrollee contact

* Contacts Enrollees/caregivers telephonically and/or in person to at time of enrollment, at time of care transition, and/or ongoing based upon Program requirements to:

* Perform a nursing needs assessment

* Assess the health needs of the Enrollees and/or


Recommend modifications to care plan elements * Completes a home visit for all community dwelling assigned Enrollees prior to or in the first month of enrollment, any time there is a clinical change, or at intervals defined by EOHHS in order to complete the Minimum Data Set Home Care (MDS HC) form and submits to EOHHS via the Virtual Gateway to obtain a rating category which determines FCHP EOHHS monthly reimbursement

* Completes a facility visit for all long term care dwelling assigned Enrollees prior to or in the first month of enrollment, any time there is a clinical change, or at intervals defined by EOHHS in order to obtain and validate the Minimum Data Set 3.0 form completed by the long term care facility which determines the FCHP EOHHS monthly reimbursement. The NCM ensures the Navigator sends the MDS 3.0 forms to EOHHS per Department process

* Manages the Enrollee panel to ensure there are not lapses in the EOHHS rating category approvals (lapses may result in reductions in State funding)

* Responsible for updating and maintaining accuracy of panel access data base lists processes according to Department guidelines

* Performs Enrollee assessments for supportive programs paid for the Program including but not limited to the Personal Care Attendant (PCA) Program. The NCM s assessment of the Enrollee s need for hands on PCA services determines the number of hours of PCA the Program will pay for on a weekly basis

* Is a member of the Enrollee s PCT and attends all meetings even if not actively involved with the Enrollee providing suggestions and feedback as appropriate

* Works closely with the Enrollee s Navigator to initiate PCT meetings with PCT members/enrollees/caregivers as necessary and ensures the Navigator coordinates the participation of appropriate interdisciplinary team members

* As a member of the PCT, updates all relevant team members regarding the Enrollee s status and develops/proposes changes to the care plan (PCT approves changes)

* Documents in the FCHP UM Staff Inpatient Case whenever an Enrollee has an inpatient event to ensure the FCHP UM Staff know the Enrollee situation and discharge planning needs

* Works with members of the PCT/FCHP UM staff, assisting with difficult or complex care delivery or discharge planning needs

* Attends facility discharge planning rounds, advocating for Enrollee care needs and facilitation of care plans that meet care needs

* Works with PCT members to coordinate a continuum of care for Enrollees consistent with the Enrollee s health care goals and needs

* Identifies, aligns, and utilizes health plan and community resources that impact high-risk/high cost care

* Creates contingency plans for each step of the process to anticipate treatment and service complications, while ensuring that the Enrollee attains pre-determined outcomes

* Resolves conflicts among participants in the care planning process

* Streamlines the focus of the Enrollee s healthcare needs utilizing the most optimal treatment approach, promoting timely provision of care, enhancing quality of life, and promoting cost-effectiveness of care

* Works collaboratively and cohesively with all members of the Primary Care Team (including the Primary Care Physician, Geriatric Social Service Coordinators from the Aging Service Access Points, Long Term Care Facility Liaisons, Enrollees/caregiver and others including but not limited to the Program Behavioral Health Clinician) as appropriate

* Reviews Enrollees with the Program Geriatrician and advocates for Administrative Exception considerations as appropriate

* Coordinates and approves services provided by skilled home health care agencies and in home/facility providers to coordinate plans for Enrollees served in the Program

* Maintains an ongoing awareness of clinical, social, and financial resources available in the community/long term care setting as well as State/Federal and national resources

* Maintains documentation of individual care management plans, interventions, cost/benefit analyses, and other statistics as needed, to demonstrate the clinical quality outcomes and cost-effective financial impact of care management

* Uses the appropriate FCHP IT application(s) including the Centralized Enrollee Record to document all case activity and facilitate appropriate communication between the PCT Team

* Uses the FCHP Core System to view eligibility and status of authorizations

* Utilizes a successful communication style and methods to engage Enrollee s in care management does not easily give up and works to engage Enrollee s as appropriate

* Identifies and shares best practices and innovative care management strategies with the team

* Supports department colleagues, covering and assuming changes in assignment as assigned by Supervisor/Designee

* Strictly observes HIPPA regulations and the FCHP policies regarding confidentiality of member information


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

* Certification in Case Management strongly desired

* A minimum of three to five years clinical experience as a Registered Nurse managing chronically ill/geriatric patients.

* Experience working in a healthcare setting as a member of a professional clinical team required.

* Experience with care coordination.

* Experience in home health care, working with Enrollees who are in a long term care setting and familiarity with the MDS process a plus.

* One year experience as a case manager in a managed care setting a plus.

Fallon Health is an equal opportunity employer. It is very important for us to maintain a consistant hiring process for every candidate. In addition, we are also a government contractor with requirements to report on our Affirmative Action planning. To that end, we require everyone to apply online.

If you do not have access to a computer or need assistance completing the application process, please contact Human Resources at 1-508-368-9893 (TRS 711).