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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 Navigator 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. The Navigator partners with Fallon Health Care Team staff and other providers to always communicate what is occurring with the member and their status. The Navigator seeks to establish telephonic and face to face (depending upon product and circumstance) relationships with the member/caregiver(s) and provider partners to better ensure ongoing service provision and care coordination, consistent with the member specific care plan. To effectively advocate for member needs, the Navigator may make in home or facility visits (depending upon the product and circumstances) with or without other Care Team members to fully understand a member’s care needs.

Responsibilities include but are not limited to:

Utilizes an ACD line to support department and incoming/outgoing calls with the goal

of first call resolution with each interaction

Conducting telephonic and may conduct face-to-face member visits to assess members utilizing TruCare Assessment Tools

Establishing and developing effective working relationships with community partners

such as housing staff, adult day health care staff, assisted living staff, group adult foster and adult foster care staff, rest home staff, long term care facilities and other providers including primary care providers with the goal to facilitate member specific communication, represent Fallon Health in a positive and effective manner, and work to grow membership in the various Fallon Health products as applicable

Educating members/PRAs about their product specific benefits and how to access often times facilitating and coordinating such

Help members to ensure physician office visits are scheduled and attended

Places referrals and following up to ensure services are in place as per the individual care plan and developing a care plan in conjunction with the Care Team, preparing and sending member specific care plans per process

Performs care coordination for members adhering to contact and duration frequencies documenting all activities in the TruCare system utilizing the appropriate assessment and/or note type following Clinical Integration Documentation Policy

Contacts members to resolve gaps in care including but not limited to: PCP assignment, PCP visits, preventative screenings, vaccination reminders, and other initiatives as assigned

Help members obtain access to care including but not limited to working with providers to arrange medical and behavioral health appointments and following up with members afterwards to ensure they attended, if not determine barriers, and work to have members attend appointments as required

If working on the NaviCare Member Population: Facilitates transportation to medical, behavioral health, and social appointments by educating the member about the process to request transportation and/or working to assist the member to obtain such

If working on the ACO Member Population: Facilitates transportation to medical and behavioral health appointments by completing the MassHealth PT-1 process on behalf of the member/provider

Educates members and assists members to obtain community benefits including but not limited to food through the EBT system, fuel assistance and other community programs and services such as WIC

Screens members for social determinants and service needs and refers members to Clinical Team members and

Partners for intervention based upon criteria and processes

If working on the ACO or Commercial Products and depending upon process: May contact maternity members after

hospital discharge to facilitate delivery of items as part of the ‘Oh Baby’ program and work with Nurse Case Managers to coordinate after care needs

The Navigator refers to the Nurse Case Manager/PCP whenever clinical decision making is required.

Responsibilities

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

Member Education, Advocacy, and Care Coordination

Utilizes an ACD line to support department and incoming/outgoing calls with the goal of first call resolution with each interaction

Performs tasks and actions to ensure all CMS and State member related regulatory mandates are met including but not limited to welcome calls, care plans, health risk assessments/care needs screening for the member population, and member service plans according to Program Policy and Process for the particular member product

Monitors the daily inpatient census and notifies all members of the care team during member care transitions including any discharge planning updates depending upon the product process

Works collaboratively with Embedded Navigators and Transition of Care Team RNs

Follows up with members following transition of care to ensure member attended follow up appointments, if they have any questions or concerns, and ensures all members of the Care Team are knowledgeable about the care transition and work collaboratively to ensure the member care plan meets needs

May conduct visits to hospital and Nursing Facilities during a Care Transition to participate in the discharge planning process (depending upon the product and circumstances)

May perform home visits with members (depending upon the product and circumstances). Visits may be by self, or with others on the Care Team

Responds promptly to member calls/questions and follows up per department processes at all times demonstrating exceptional customer service skills in a culturally sensitive way

Provides culturally appropriate care coordination i.e.: arranges for interpreters, provides communication documents in appropriate language, demonstrates culturally appropriate behavior when working with member/family

Develops and fosters relationships with members and providers/facilities and depending upon the product, to be the first point of contact for benefit related questions and is able to explain processes including but not limited to: coverage criteria, appeal rights and processes, authorization request process, formulary, and evidence of coverage details

Manages member panel in conjunction with other employed Clinical Integration Team members; depending on the Fallon Health product, with the contracted Aging Service Access Point Geriatric Support Service Coordinator when applicable; and/or Community Partners; and contracted primary and specialty care providers – this includes conducting face to face or telephonic health risk assessments in a culturally sensitive way, completing care plans, and reviewing claims and other data which may indicate a need for Nurse Case Manager involvement and assessment

Assists the interdisciplinary team in identifying and addressing member barriers related to social determinants of health and care obtainment

Collaborates with the interdisciplinary team in identifying and addressing high risk members and transitions of care

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 community senior/cultural centers and other external partners

Maintains up to date knowledge of Program/Product 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

Participates in member retention efforts by providing benefit advice and clarification upon knowledge of member dissatisfaction and potential to voluntarily leave the plan, as applicable

Collaborates with appropriate team members to ensure health education/disease management information is provided as identified

Educate members on preventative screenings and other health care procedures such as vaccines and screenings according to established protocols

Provider Partnerships and Collaboration

May attend in person care plan meetings with partners and providers and leads care plan review with partners and providers and care team

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

Ensures accurate membership reports based upon provider/facility, distributes reports ensuring accuracy of data, updates and maintains provider sheets as applicable

Access to Care

Depending upon the product, generates requests and authorizations for Medicaid covered services per the member care plan ensuring all services requiring authorization have accurate and timely authorizations in place in the Fallon Health system with accuracy and timeliness per program process depending upon the member product and workflows

Educates members and providers on authorization processes, educates about authorization review outcomes, works to resolve authorization related issues and concerns depending upon the member product and workflows

Follows through to ensure services/authorizations are in place as per the care plan, and if not, takes action for successful resolution

Facilitates member access to Program benefits, providing education about coverage criteria, explaining processes for member request determinations and helping members navigate the managed care system

Care Team Communication

Follows established transition of care workflow including but not limited to: communicating to all members of the Care Team when a care transition occurs and documents per workflow

Works collaboratively and ensures communication with members of the Care Team including but not limited to, medical providers, and member/PRAs to ensure member care plan supports their needs

If working on the NaviCare product line, partners with the Long Term Care Team/Community Team when members are admitted to custodial care and/or discharged to the community to ensure admission and discharge planning needs for the member are met

May partner closely with the Advanced Practitioner staff to ensure facility and member needs are being met

Regulatory Requirements-Actions and Oversight

Depending upon member product, performs tasks and actions to ensure all CMS/State/NCQA related regulatory mandates are met including but not limited to Care Needs Screenings, Welcome Calls, Care Plans, Health Risk Assessments, and member Service Plans according to Program Policy and Process

Completes timely Care Needs Screening, Health Risk Assessments, Service Plans, and Care Plans in the TruCare system (care management platform) according to Regulatory Requirements and Program policies and processes

Reviews and validates data on Member Panel report generated from the TruCare ensuring member contacts, programs, services are accurate and up to date at all times for members on panel

Reviews claims and other reports monitoring for triggers and events that may warrant nurse case manager action (such as high dollar claims that may trigger a State assigned rating category change for NaviCare and ACO members) for members on panel

Maintains and updates TruCare and associated reports per Program processes for members on panel

Knowledge of and compliance with HEDIS and Medicare 5 Star measure processes performing member education

Utilize reports identifying gaps in care and follow up per program protocol

Obtains medical records and other required documents from the health care providers and ensures uploading into TruCare

Performs other responsibilities as assigned by the Manager/designee

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

May mentor and train staff on processes associated with job function and role.

Qualifications

Education:

College degree (BA/BS in Health Services or Social Work) preferred

License/Certifications:

License: N/A

Certification: None

**Other** : Satisfactory Criminal Offender Record Information (CORI) results and access to reliable transportation

Experience:

2+ years job experience in a managed care company, medical related field, or community social service agency required

Understanding of hospitalization experiences and the impacts and needs after facility discharge required

Knowledgeable about medical terminology and basic understanding of common disease processes and conditions required

Knowledgeable about medical record documentation and able to recognize triggers requiring RN intervention required

Experience with telephonic interviewing skills and working with a diverse population, that may also be Non-English speaking required

Understanding of the impacts of social determinants of health required

Knowledgeable about software systems including but not limited to Microsoft Office Products – Excel, Outlook, and Word required

Experience working in a community social service agency, skilled home health care agency, community agency such as adult foster care, group adult foster care, personal care management agency, independent living agency, State Agency such as the Department of Mental Health (DMH), Department of Developmental Services (DDS), Department of Children and Families (DCF), and/or the Department of Youth Services (DYS), or other agency servicing those in need preferred

Experience in a nursing facility or in a Massachusetts Aging Access Service Point Agency preferred

Experience working on a multi-disciplinary care team in a managed care organization 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 about community resources available to assist the member population in the community and long term care settings and demonstrated willingness to seek resources and expand knowledge to assist the population

Willingness to learn insurance regulatory and accreditation requirements

Familiar with Excel spreadsheets to manage work and exposure and familiarity with pivot tables

Accurate and timely data entry

Effective care coordination skills and the ability to communicate, advocate, and follow through to ensure member needs are met

Knowledgeable regarding community resources

Ability to communicate effective to physician and other medical providers

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, shifting priorities, ambiguity, and rapid change

+ Demonstrates flexibility

+ Written Communication

+ Is able to write clearly and succinctly in a variety of communication settings and style

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

**Location** _US-MA-Springfield_

**Posted Date** _7 hours ago_ _(5/22/2025 1:15 PM)_

**_Job ID_** _7955_

**_\# Positions_** _1_

**_Category_** _Other_