RN Nurse Case Manager -Holyoke - Spanish Speaking Preferred.
Company: Fallon Community Health Plan
Posted on: March 16, 2019
RN Nurse Case Manager -Holyoke - Spanish Speaking Preferred. Job ID: 5407# Positions: 1Posted Date: 2019-01-17Category: NursingProduct Line:Overview:About Fallon HealthFounded in 1977, Fallon Health is a leading health care services organization that supports the diverse and changing needs of those we serve. In addition to offering innovative health insurance solutions and a variety of Medicaid and Medicare products, we excel in creating unique health care programs and services that provide coordinated, integrated care for seniors and individuals with complex health needs. Fallon has consistently ranked among the nation's top health plans, and is accredited by the National Committee for Quality Assurance for its HMO, Medicare Advantage and Medicaid products. For more information, visit fallonhealth.org.About NaviCare:Fallon Health is a leader in providing senior care solutions such as NaviCare, a Medicare Advantage Special Needs Plan and Senior Care Options program. Navicare integrates care for adults age 65 and older who are dually eligible for both Medicare and MassHealth Standard. A personalized primary care team manages and coordinates the NaviCare member's health care by working with each member, the member's family and health care providers to ensure the best possible outcomes.Brief Summary of purpose:Assess a member's clinical/functional/behavioral health status and use this information to provide case management and care coordination for the member across the continuum of care which is consistent with a member's health care needs and goalsSupport members at time of care transition, advocating at time of discharge and facilitation with the primary care team to ensure the care plan is effective to meet care needs teaching about disease process, medications, and other strategies as requiredCollaborating with all members of the primary care team, the member, designated care givers, and others involved in the member careAssess members for long term services and supports and apply coverage criteria to determine level of care and number of hours for programs such as personal care attendant, group adult foster care, adult foster care, short term custodial care, and other long term services in supports in collaboration with the Aging Service Access Point staff, long term care facilities, and members of the primary care teaCommunicate with primary care providers and other medical and service providers about a member's clinical status and needsDocument all actions/assessments/care coordination in the documentation system according to Program Policy and ProcessComplete regulatory mandates per requirements including but not limited to Health Risk Assessments, Care Plans, MDS HC assessments and submissions in the State Virtual GatewayStrictly observes HIPAA regulations and the Fallon Health Policies regarding confidentiality of member informationResponsibilities:Member Assessment, Education, and AdvocacyIn collaboration with the NaviCare Outreach Team, works to facilitate a smooth new member onboarding experience and provides excellent customer service at all timeConducts in home face to face visits to assigned community dwelling members with member's consent. Visits may be by self, or with others of the Primary Care Tea Utilizing clinical judgment and nursing assessment skills, completes the Program Health Risk Assessment Tools and Minimum Data Set Home Care (MDS HC) Form within the first month of enrollment, and at intervals defined by the Program ensuring members are in the correct State defined rating categoryDemonstrates knowledge of the NaviCare benefits and applies coverage criteria, payment policy, and MassHealth guidelines when developing and implementing member care plans teaching members and other members of the primary care team about benefits, qualifications, and coverage criteriaUtilizes a variety of interviewing techniques, including motivational interviewing, and employs culturally sensitive strategies to engage and work with membersAssesses the Member's knowledge about the management of current disease processes and medication regimen and provides teaching to increase Member/caregiver knowledgeEducates the member/caregivers to ensure enhancement of effective self-management skills and educates and provides caregiver education and supportAssesses members at time of care transition and completes assessmentsEnsures members/PRAs participate in the development and approval of their care plans in conjunction with the interdisciplinary primary care teamCare Coordination and CollaborationProvides 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 representativesManages complex community members in the 'AD/CMI' and 'Nursing Home Certifiable' rating categories in conjunction with the Navigators, Behavioral Health Case Managers, Aging Service Access Point Geriatric Support Service Coordinators, contracted Primary Care Providers and others involved/authorized in the member's careWith member/authorized representative(s) collaboration develops member centered care plans by identifying member care needs while completing program assessments and developing care plans working with the Navigator to ensure the member approves their care planMonitors 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 needsCare Transitions - per Program Processes:Works closely with the Navigator, who closely monitors the daily inpatient census, to learn when the member has a care transition Communicates and coordinates member care needs and discharge plans with Fallon Health Utilization Management staffParticipates in discharge planning meeting at the facility to ensure member care needs are met before and after dischargeFollows up with member/PRA telephonically or in person after discharge to perform Transition of Care assessment, medication reconciliation, and ensure services are in place as care planned within designated time framesWorks collaboratively with Fallon Health Pharmacist, referring members in need of medication review based upon Program processDevelops 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 careCollaborates with Navigators who manage the 'Community Well' members and performs clinical care transition assessments and other health risk assessments when members experience a care transition or other triggers that warrant an assessment of rating category status - always involved with any 'clinical' issues and care coordination needs for this populationReviews and validates data on Member Panel report generated from TruCare and takes action to ensure accurate dataRegulatory Requirements - Actions and OversightCompletes Health Risk Assessments, Minimum Data Set Home Care (MDS HC) Assessments, Transition of Care Assessments, and Care Plans in the Centralized Enrollee Record and Virtual Gateway according to Regulatory Requirements and Program policies and processes Reviews member claims and available reports to determine if a change in status may warrant MDS HC submission to the Virtual Gateway facilitating the appropriate State rating categoryKnowledge of and compliance with HEDIS and Medicare 5 Star measure processes, performing member education, outreach, and actions in conjunction with the Navigator Provider Partnerships - Collaboration - Work with Fallon Health TeamsDemonstrates knowledge of the NaviCare benefits and coverage criteria and fosters collaborative working relationships with vendor and provider staffDemonstrates positive customer service actions and works with the Navigators and Behavioral Health Case Managers to ensure member and provider requests and needs are metWhen invited by Outreach/Provider Relations/NaviCare Clinical Leadership Team attends and contributes Model of Care trainings/orientations with providers and/or vendors explaining the various roles of the clinical team in coordination of member's carePerforms and may lead face to face or in-person member care plan review with providers including but not limited to Primary Care Providers, Aging Service Access Point Providers, Long Term Services and Support Providers, Behavioral Health Providers, Long Term Care Facility Providers, and/or any other Provider/Member/Authorized Representatives to ensure effective communication and collaboration between all involvedMay be embedded in certain Provider Facilities and works collaboratively with Provider Facility staff maintaining professional communications and educates about NaviCare benefits, coverage criteria, enrollment requirements and other Program related detailsPartners with interdepartmental teams (including but not limited to: Utilization Management, Appeals and Grievance, NaviCare Operations, Provider Relations, Pharmacy..... click apply for full job details
Keywords: Fallon Community Health Plan, Springfield , RN Nurse Case Manager -Holyoke - Spanish Speaking Preferred., Executive , Springfield, Massachusetts
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