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 is an integral part of the Fallon Health interdisciplinary team and communicates members needs to providers and other community supports, while ensuring all members of the care team are informed of member issues and concerns. The Navigator seeks to establish telephonic relationships with the member/caregiver(s) and provider partners to better ensure ongoing service provision and care coordination, consistent with the member needs. To effectively advocate for member needs, the Navigator must be a subject matter expert in benefit structure and coverage of both Community Care and Medicare product lines. The Navigator must also have working knowledge of all products offered by Fallon Health to refer members as appropriate as well as a basic understanding of Mass Health guidelines. Further, the Navigators are subject matter experts on all social care needs, assisting members in obtaining the care and support that they need to get needed care and to remain in the community safely. The Navigator must be familiar with quality metrics including STARS and HEDIS as well as guiding factors within the NCQA standards as well as CAHPS survey questions to best align members’ care to meet these metrics.
Responsibilities
Primary Job Responsibilites
Note: Job Responsibilities may vary depending upon the member’s Fallon Health Insurance Product
Member Education, Advocacy, and Care Coordination
- Telephonically manages incoming/outgoing calls with the goal of first call resolution with each interaction
- Conducts telephonic (face to face if required) member visits to assess member needs utilizing TruCare Assessment Tools
- Establish and develop effective working relationships with community partners such as Elder Services, community organizations, 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
- Educate members/PRAs about their product specific benefits and how to access often times facilitating and coordinating such
- Educates members/PRAs on referrals and prior authorizations- assists members in obtaining these as needed
- Provides education to providers on prior authorizations and referrals
- 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
- Assists the interdisciplinary team in identifying and addressing member barriers related to social determinants of health and care obtainment
- Collaborate 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. Must maintain this knowledge for both Community Care and Medicare.
- 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
- 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
- Manages all Transition of Care administrative work including, but not limited to, PointClickCare tasking of discharge notifications to Nurse/Behavioral Health Case Managers, obtaining discharge medical records, schedules follow up appointments, identifies discharges not captured by PointClickCare to ensure timely follow up, identification of high risk for readmission members, and ordering Moms Meals for Medicare members as requested
Provider Partnerships and Collaboration
- 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
- Demonstrates positive customer service actions and takes responsibility to ensure member and provider requests and needs are met
- 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 Establish and develop effective working relationships with community partners such as Elder Services, community organizations, 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
- Provides education to providers on prior authorizations and referrals
Access to Care
- 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 for both Medicare and Community Care
- Identifies members who do not have a primary care provider and engage members with the goal of establishing members with primary care providers
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
- Participates in multidisciplinary case rounds
- Ensure Nurse Case Managers are notified of any clinical concerns
- Ensures Behavioral Health Case Managers are notified of any behavioral health concerns
Regulatory Requirements – Actions and Oversight
- Depending upon member product, performs tasks and actions to ensure all CMS/State/NCQA related regulatory mandates are met
- Reviews claims and other reports monitoring triggers and events that may warrant nurse case manager action 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
EducationCollege 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
Expereince:
- 2+ years of experience working with people of all ages with a focus on working with people that may be encountering social, economic, and/or multi complex medical and or behavioral health conditions 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/Social Worker intervention required
- Experience with telephonic interviewing skills and working with a diverse population, that may also be non-English speaking
- Understanding of the impacts of social determinants of health
- Knowledgeable about software systems including but not limited to Microsoft Office Products – Excel, Outlook, and Word required
- Experience conducting face to face member visits and interacting with providers and community partners preferred
- 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 Service Access 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, as needed, 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
- Closes loop on all SDOH member needs included, but not limited to, transportation, food resources, household goods, prescription assistance, state agency supports, assistive technology and technology and cash assistance.
- Knowledgeable regarding community resources and services to address members complex medical, behavioral and social needs
- Ability to solve problems and independently search for solutions to member problems using available resources and search tools
- Ability to communicate effectively to physicians and other medical providers
- Assists BHCMs in finding specialty BH 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
- Able to write clearly and succinctly in a variety of communication settings and style
- Oral Communication
- Able to effectively communicate with members, providers and community supports
- Effective interviewing skills to draw information from members to create cohesive and effective care plans
Pay Range Disclosure:
In accordance with the Massachusetts Wage Transparency Act, the pay range for this position is $28 - $30 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.
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