Nurse Case Manager jobs at Fallon Health - 89 jobs

This position covers Boston/Suffolk County plus surrounding Middlesex County including Allston, Ashland, Auburndale, Babson Park, Belmont, Boston/East Boston, Brighton, Brookline, Brookline Village, Cambridge, Charlestown, Chestnut Hill, Dover, Framingham, Hyde Park, Jamaica Plain, Mattapan, Natick, Needham, Needham Heights, Newton, Newtonville, Nonatum, North Waltham, Waltham, Readville, Roslindale, Sherborn, Somerville, Waban, Watertown, Waverley, Wayland, Wellesely, West Newton, West Roxbury and Weston. 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. #P01

The Telephonic Case Manager RN in Medical Oncology provides remote nursing support by coordinating patient care, educating members, and ensuring adherence to treatment plans. This role involves assessing patient health, identifying barriers, and connecting patients with necessary resources to improve health outcomes. Working primarily via telephone, the position requires strong clinical expertise, communication skills, and proficiency in healthcare technology systems. Optum is a global organization that delivers care, aided by technology to help millions of people live healthier lives. The work you do with our team will directly improve health outcomes by connecting people with the care, pharmacy benefits, data and resources they need to feel their best. Here, you will find a culture guided by diversity and inclusion, talented peers, comprehensive benefits and career development opportunities. Come make an impact on the communities we serve as you help us advance health equity on a global scale. Join us to start Caring. Connecting. Growing together. We're making a solid connection between exceptional patient care and outstanding career opportunities. The result is a culture of performance that's driving the health care industry forward. As a Telephone Case Manager RN with UnitedHealth Group, you'll support a diverse member population with education, advocacy and connections to the resources they need to feel better and get well. Instead of seeing a handful of patients each day, your work may affect millions for years to come. Ready for a new path? Apply today! The Telephonic Case Manager RN Medical/Oncology will identify, coordinate, and provide appropriate levels of care. The Telephonic Case Manager RN Medical/Oncology is responsible for clinical operations and medical management activities across the continuum of care (assessing, planning, implementing, coordinating, monitoring and evaluating). This includes case management, coordination of care, and medical management consulting. This is a full-time, Monday - Friday, 8am-5pm position in your time zone. You'll enjoy the flexibility to work remotely* as you take on some tough challenges. Primary Responsibilities: Make outbound calls and receive inbound calls to assess members current health status Identify gaps or barriers in treatment plans Provide patient education to assist with self-management Make referrals to outside sources Provide a complete continuum of quality care through close communication with members via in-person or on-phone interaction Support members with condition education, medication reviews and connections to resources such as Home Health Aides or Meals on Wheels This is high volume, customer service environment. You'll need to be efficient, productive and thorough dealing with our members over the phone. Solid computer and software navigation skills are critical. You should also be solidly patient-focused and adaptable to changes. You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in. Required Qualifications: Current, unrestricted RN license in state of residence Active Compact RN License or ability to obtain upon hire 3+ years of experience in a hospital, acute care or direct care setting Proven ability to type and have the ability to navigate a Windows based environment Have access to high-speed internet (DSL or Cable) Dedicated work area established that is separated from other living areas and provides information privacy Preferred Qualifications BSN Certified Case Manager (CCM) 1+ years of experience within Medical/Oncology Case management experience Experience or exposure to discharge planning Experience in a telephonic role Background in managed care *All employees working remotely will be required to adhere to UnitedHealth Group's Telecommuter Policy. At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone-of every race, gender, sexuality, age, location and income-deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes - an enterprise priority reflected in our mission. Diversity creates a healthier atmosphere: UnitedHealth Group is an Equal Employment Opportunity/Affirmative Action employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law. UnitedHealth Group is a drug - free workplace. Candidates are required to pass a drug test before beginning employment. Keywords: telephonic case management, oncology nurse, patient education, care coordination, medical management, healthcare advocacy, remote nursing, chronic disease management, UnitedHealth Group, RN license

Full Time RN Manager at Allied Digestive Health summary: The Full-Time Nurse Manager leads nursing staff and oversees daily nursing operations at Albany Gastroenterology Consultants, ensuring high-quality patient care and compliance with nursing regulations. They manage schedules, mentor nursing staff, collaborate with healthcare providers, and maintain a safe and efficient work environment. The role requires a registered nurse with at least five years of nursing experience and 3-4 years in management. Full Time Nurse Manager Job Description Allied Digestive Health is one of the largest integrated networks of gastroenterology care centers in the nation with over 200 providers and 60 locations throughout New Jersey and New York. As a fast-growing physician-led organization, our dynamic structure encourages physician input and decision-making, while simultaneously offering operational support. Our dedicated, compassionate team of providers prioritize personalized treatment plans for patients that deliver the highest quality of care. All of our doctors are board-certified in gastroenterology and hepatology. Several of them serve as chief of gastroenterology at nearby hospitals, and a number of them have been recognized as top-quality physicians in publications, including but not limited to: Best Doctors in America and Top Doctors New Jersey, and US News Health - US News & World Report. We are excited to announce that we are looking for a Full-Time Nurse Manager at Albany Gastroenterology Consultants of Albany New York. To Learn more about our practice please click the link below Job Summary: The Nurse Manager is responsible for managing and supervising various departments within the Practice. They have a wide range of knowledge of basic patient wellbeing. Experienced in both nursing and management, the nurse manager is also trained to supervise and guide nurses and nursing programs. The Nurse Manager Responsibilities are: Promote and restore patients' health by developing day-to-day management Direct and develop nursing staff by creating schedules, offering advice, and answering any health-related questions Collaborates with providers Enforces adherence to the state board of nursing and state nurse practice requirements. Maintains nursing staff by recruiting, selecting, orienting, and training nurses and auxiliary staff. Completes patient care requirements by scheduling and assigning nursing and staff. Maintains nursing staff by coaching, counseling, and disciplining through monitoring and appraising nurses' job performance. Provides information to patients and the health care team by answering questions and requests. Maintains a safe and clean working environment by designing health procedures and protocols. Maintains a cooperative relationship among health care teams by communicating information and participating in team-building exercises. The Nurse Manager must have the following qualifications and experience: Associates or bachelor's degree in nursing from an accredited college or university Registered Nurse (RN) required Minimum of 5 years nursing experience Minimum of 3-4 years management experience with the ability to provide leadership to the department Key Benefits: Health Benefits Day one to include Major Medical, Dental, Vision, Prescription, Life insurance, and disability 401K 3% safe harbor contribution Sign on Bonus of $500.00 PTO Employee Assistance Program Commuter Benefits About the Community: Located in Albany, NY is located on the historic Hudson River. Albany has a vibrant culture with influence from NYC to the south, and Montreal to the North! There are beautiful festivals, and theater productions! Great neighborhoods and schools make Albany a great location to grow a practice in a vibrant community Keywords: Nurse Manager, Registered Nurse, Nursing Leadership, Healthcare Management, Patient Care, Gastroenterology, Healthcare Team Collaboration, Nursing Staff Scheduling, Healthcare Compliance, Medical Practice Management

Full Time Triage RN at Allied Digestive Health summary: The Full-Time Triage Registered Nurse (RN) at Albany Gastroenterology Consultants provides critical patient care coordination by managing incoming calls, scheduling appointments, handling prior authorizations, and communicating test results. The RN collaborates closely with physicians and advanced practice providers to ensure personalized, high-quality care for gastroenterology patients. This role requires a current NY RN license and experience in a medical office setting, offering competitive benefits and support in a vibrant Albany community. Job Description Albany Gastroenterology Consultants have partnered with Allied Digestive Health which is one of the largest integrated networks of gastroenterology care centers in the nation with over 200 providers and 60 locations throughout New Jersey and New York. As a fast-growing physician-led organization, our dynamic structure encourages physician input and decision-making, while simultaneously offering operational support. Our dedicated, compassionate team of providers prioritize personalized treatment plans for patients that deliver the highest quality of care. All of our doctors are board-certified in gastroenterology and hepatology. Several of them serve as chief of gastroenterology at nearby hospitals, and a number of them have been recognized as top-quality physicians in publications, including but not limited to: Best Doctors in America and Top Doctors New Jersey, and US News Health - US News & World Report. We are excited to announce that we are looking for a Full-Time Registered Nurse Triage at Albany Gastroenterology Consultants of Albany New York. To learn more about this practice, click the link below: The Registered Nurse Triage Responsibilities are: Work closely with physicians, NP and PAs. Report directly to the nursing Manager. Handle all incoming sick patient phone calls for assigned providers. Make appointment: Office visits, referrals, imaging studies, lab. Prior authorization: Medications, imaging studies, labs. Notify patient of results on the portal, by email or phone call. Respond to patient portal messages. Logging of all procedures, act on orders; make sure pathology reports come in. Prescription refills: Review chart, scheduled appointment if needed send to provider for authorization. The Registered Nurse Triage must have the following qualifications and experience: High School graduate or GED. Graduate of accredited school of nursing. Current licensure as a registered nurse in the state of NY BCLS/ACLS preferred. Must have office medical office experience Key Benefits: Competitive Base salary Health Benefits Day One to include Major Medical, Dental Vision, Prescription, Life Insurance and Disability 401k 3% safe harbor contribution Licensure Reimbursement PTO *Sign on bonus of $500.00 About The Community Located in Albany, NY is located on the historic Hudson River. Albany has a vibrant culture with influence from NYC to the south, and Montreal to the North! There are beautiful festivals, and theater productions! Great neighborhoods and schools make Albany a great location to grow a practice in a vibrant community! Keywords: triage nurse, registered nurse, gastroenterology, patient care coordination, medical office, prior authorization, appointment scheduling, patient communication, RN license NY, healthcare nursing

🚨 Now Hiring: RN Case Manager - New York 🚨 💻 Work from home + local field travel 💰 Salary: $52,656 - $96,287 annually 🎉 Quarterly Bonus Opportunities 📚 Free CEUs for licenses & certificates 💳 License & Certification Reimbursement We're looking for an RN with a passion for case management to join our team! ✨ RN degree required ✨ National Certification preferred (CCM, CRC, COHN, CRRC) ✨ Workers' Comp Case Management experience a plus 📍 Location Requirement Candidates must be based in one of these New York areas: Poughkeepsie, Newburgh, and Middletown. ✅ Your Impact: You'll provide effective case management services in a cost‑effective manner, delivering medical case management consistent with URAC standards, CMSA Standards of Practice, and Broadspire QA Guidelines. You'll support patients/employees receiving benefits under insurance lines including Workers' Compensation, Group Health, Liability, Disability, and Care Management. This is your chance to grow your career, earn great rewards, and enjoy true work-life balance. 👉 Apply today and make an impact in the community! Associate's degree or relevant course work/certification in Nursing is required; BSN Degree is preferred. Minimum of 1-3 years diverse clinical experience and one of the below: Certification as a case manager from the URAC-approved list of certifications (preferred); A registered nurse (RN) license. Must be compliant with state requirements regarding national certifications. General working knowledge of case management practices and ability to quickly learn and apply workers compensation/case management products and services. Excellent oral and written communications skills to effectively facilitate return-to-work solutions within a matrix organization and ensure timely, quality documentation. Excellent analytical and customer service skills to facilitate the resolution of case management problems. Basic computer skills including working knowledge of Microsoft Office products and Lotus Notes. Demonstrated ability to establish collaborative working relationships with claims adjusters, employers, patients, attorneys and all levels of employees. Demonstrated ability to gather and analyze data and establish plans to improve trends, processes, and outcomes. Excellent organizational skills as evidenced by proven ability to handle multiple tasks simultaneously. Demonstrated leadership ability with a basic understanding of supervisory and management principles. Active RN home state licensure in good standing without restrictions with the State Board of Nursing. Must meet specific requirements to provide medical case management services. Minimum of 1 National Certification (CCM, CDMS, CRRN, and COHN) is preferred. If not attained, must plan to take certification exam within proceeding 36 months. National certification must be obtained in order to reach Senior Medical Case Management status. Travel may entail approximately 70% of work time. Must maintain a valid driver's license in state of residence. #LI-RG1 Reviews case records and reports, collects and analyzes data, evaluates injured worker/disabled individual's medical status, identifies needs and obstacles to medical case resolution and RTW by providing proactive case management services. Render opinions regarding case costs, treatment plan, outcome and problem areas, and makes recommendations to facilitate case management goals to include RTW. Demonstrates ability to meet administrative requirements, including productivity, time management and QA standards, with a minimum of supervisory intervention. May perform job site evaluations/summaries to facilitate case management process. Facilitates timely return to work date by establishing a professional working relationship with the injured worker/disabled individual, physician, and employer. Coordinate RTW with injured worker, employer and physicians. Maintains contact and communicates with claims adjusters to apprise them of case activity, case direction or secure authorization for services. Maintains contact with all parties involved on case, necessary for case management the injured worker/disabled individual. May obtain records from the branch claims office. May review files for claims adjusters and supervisors for appropriate referral for case management services. May meet with employers to review active files. Makes referrals for Peer reviews and IME's by obtaining and delivering medical records and diagnostic films, notifying injured worker/disabled individual and conferring with physicians. Utilizes clinical expertise and medical resources to interpret medical records and test results and provides assessment accordingly. May spend approximately 70% of their work time traveling to homes, health care providers, job sites and various offices as required facilitating RTW and resolution of cases. Meets monthly production requirements and quality assessment (QA) requirements to ensure a quality product. Reviews cases with supervisor monthly to evaluate files and obtain directions. Upholds the Crawford and Company Code of Business Conduct at all times. Demonstrates excellent customer service, and respect for customers, co-workers, and management. Independently approaches problem solving by appropriate use of research and resources. May perform other related duties as assigned.

Department: CASE MANAGEMENT Job Type: Regular Employment Type: Full-Time Salary Range: $155,000.00 - $170,000.00 Empower. Unite. Care. MetroPlusHealth is committed to empowering New Yorkers by uniting communities through care. We believe that Health care is a right, not a privilege. If you have compassion and a collaborative spirit, work with us. You can come to work being proud of what you do every day. About NYC Health + Hospitals MetroPlusHealth provides the highest quality healthcare services to residents of Bronx, Brooklyn, Manhattan, Queens and Staten Island through a comprehensive list of products, including, but not limited to, New York State Medicaid Managed Care, Medicare, Child Health Plus, Exchange, Partnership in Care, MetroPlus Gold, Essential Plan, etc. As a wholly-owned subsidiary of NYC Health + Hospitals, the largest public health system in the United States, MetroPlusHealth's network includes over 27,000 primary care providers, specialists and participating clinics. For more than 40 years, MetroPlusHealth has been committed to building strong relationships with its members and providers. Position Overview Under the supervision of the Senior Director of Integrated Care Management (ICM), the Director of ICM (Medicare) provides clinical and administrative oversight for the Medicare Advantage and Integrated Benefits for Dually Eligible ("IB-Dual") populations, also known as the Medicare dual eligible special needs plan (D-SNP) line of business. This role ensures adherence to the Medicare Model of Care, CMS regulatory requirements, established policies and workflows. They are also responsible for managing the day-to-day operations of the clinical and non-clinical staff, ensuring adherence to the care management process. Most broadly, the Director ensures members are receiving the care they need and that staff are addressing the members' medical, behavioral and social needs while ensuring appropriate linkages in order for them to remain safely in the community. Work Shifts 9:00 A.M - 5:00 P.M Duties & Responsibilities * Participates in the development of the vision and strategic direction for Integrated Care Management; collaborates on the implementation of related strategies. * Supervises, plans, organizes, prioritizes, delegates, and evaluates staff and functions of the Integrated Care Management Department and Medicare line of business. * Ensure staff are care managing members in accordance with the risk stratification identified and adhering to the care management process of screening, assessing, implementing, and evaluating. * Participates in development, implementation, and annual review of the Integrated Care Management and Quality Management/Quality Improvement Plan. * Provides oversight for the implementation and adherence to the Model of Care * Ensures compliance with Federal, State and City regulations as they relate to Medicare, Medicaid, and Health Homes. * Provides oversight for Transitions of Care Process and tracking, implementing strategies to prevent readmissions and reduce hospitalizations. * Collaborates with NYC H+H and external partners on various initiatives, projects and pilot programs. * Gathers, develops and tracks data on evidence-based practice interventions. * Represents ICM at various meetings and committees as required. * Provides clinical support for the review of Quality-of-Care concerns being investigated by the Quality Management Department, and collaborates with Quality Management on HEDIS, STAR ratings and CAHPS score improvement initiatives and strategies. * Collaborates with the UM Department to manage appropriate member utilization and works with data analytics to generate reports that will illustrate the impact on members' utilization. * Drives the implementation of processes and functional enhancements which will improve the overall quality and services provided by the CM teams. * Collaborate with MetroPlusHealth customer service department to ensure that member issues and concerns are addressed and resolved in a timely manner. * Analyzes trends and implements departmental initiatives based upon data provided through the reporting of Care Management or from Quality, Data Analytics and Audit data. * Ensures comprehensive and supportive on-boarding of new hires and effective, data-driven monitoring/coaching to ensure that efficiency and performance are maximized among existing staff. * Maintains communication with the department head, offering routine updates on operations, issues, concerns, and other pertinent information. * Adheres to hybrid work model and provides staff oversight on office days. * Performs other duties as assigned by the Senior Director. Minimum Qualifications * Bachelor of Science in Nursing required. Master's Degree in Nursing preferred. * Minimum 10 years professional healthcare management * Minimum 5 years in leadership role, Manager and above * A minimum of 5 years of administrative experience with supervision of clinical and ancillary staff in a Managed care role required * Must be familiar with OMH, DOH, CMS regulations for service delivery, with a care coordination approach to service delivery in managed care settings Licensure and/or Certification Required: * Valid New York State license and current registration to practice as a Registered Professional Nurse (RN) issued by the New York State Education Department (NYSED). Professional Competencies: * Integrity and Trust * Leadership and Management Skills * Customer Focus * Functional / Technical skills * Written/ Oral Communication * Ability to successfully multi-task while under strict timetable * Exceptional Organizational skills Benefits NYC Health and Hospitals offers a competitive benefits package that includes: * Comprehensive Health Benefits for employees hired to work 20+ hrs. per week * Retirement Savings and Pension Plans * Paid Holidays and Vacation in accordance with employees' Collectively bargained contracts * Loan Forgiveness Programs for eligible employees * College tuition discounts and professional development opportunities * College Savings Program * Union Benefits for eligible titles * Multiple employee discounts programs * Commuter Benefits Programs #LI-Hybrid #MHP50

Full-time Description Case Manager I, II, III, IV ** SIGN ON BONUS ELIGIBLE ** Conifer Park is seeking a full-time Case Manager to join our clinical team in Glenville, NY. In this role, the employee assumes full charge of patient case management, delivering individual and group mental health and chemical dependency services including assessment, discharge planning, managed care, and relevant communication, formulation and implementation of treatment plans, and performing specified duties. Schedules: Sundays - Thursdays 8:00am - 4:30pm Tuesdays - Saturdays 8:00am - 4:30pm Mondays - Fridays 8:00am - 4:30pm Tuesdays - Saturdays 10:00am - 6:30pm Requirements Case Manager I Requirements: High School Diploma or GED with a minimum of 1 year of Case Management experience or applicable internship and a CASAC-T certification. Chemical dependency and/or mental health experience preferred and group counseling, didactic skills. Case Manager II Requirements: High School Diploma or GED with 1 year of Case Management experience or applicable internship and posses a current CASAC Certification. Case Manager III Requirements: Bachelor's Degree and current CASAC certification OR Master's licensable degree and a minimum of 1 year relevant experience or applicable internship Case Manager VI Requirements: Master's Licensed Degree with LMHC, LMSW or LCSW Experience in Chemical dependency and/or mental health. Experience in Group counseling and Didactic Skills We offer competitive wages, benefits, and a pension plan in a supportive working environment. Background checks, pre-employment & drug screenings required. Sign on bonus eligible position, payable in three installments for a total of $4000. We are an equal opportunity employer according to standards Schedules: Tuesdays-Saturdays 11:00am-8:00pm INDMP Salary Description $19.86 -$37.62

Full-time Description Case Managers I, II, III, IV PER DIEM OPPORTUNITIES Conifer Park is seeking Per Diem Case Managers to join our clinical team in Glenville, NY. In this role, the employee assumes full charge of patient case management, delivering individual and group mental health and chemical dependency services including assessment, discharge planning, managed care, and relevant communication, formulation and implementation of treatment plans, and performing specified duties. Requirements Case Manager I Requirements: High School Diploma or GED with a minimum of 1 year of Case Management experience or applicable internship and a CASAC-T certification. Chemical dependency and/or mental health experience preferred and group counseling, didactic skills. Case Manager II Requirements: High School Diploma or GED with 1 year of Case Management experience or applicable internship and posses a current CASAC Certification. Case Manager III Requirements: Bachelor's Degree and current CASAC certification OR Master's licensable degree and a minimum of 1 year relevant experience or applicable internship Case Manager VI Requirements: Master's Licensed Degree with LMHC, LMSW or LCSW Experience in Chemical dependency and/or mental health. Experience in Group counseling and Didactic Skills We offer competitive wages, benefits, and a pension plan in a supportive working environment. Background checks, pre-employment & drug screenings required. We are an equal opportunity employer according to standards INDHP Salary Description $19.86 -$37.62

Life Insurance Agency: Case Manager Assistant We are looking for a case manager with strong working knowledge of the Life Insurance industry for our busy independent Life Insurance agency. This assignment will be in our Great Neck office, but will require training in our New York City mid-town office for 4-6 weeks. You will be working closely with our current case management staff, as well as the Insurance Operations Manager. You will be responsible for all aspects of underwriting and case management, from submission to completion, for our internal/external agents as well as our external organizations. The ideal candidate would be someone who is flexible and willing to take direction when needed, but understands when it is necessary to be proactive and take charge. Experience in the Life Insurance industry is essential Key Responsibilities Review and submission of all new business applications to various life insurance carriers Verify if agent is appointed and licensed with the appropriate carrier and state with internal licensing department. Enter case information into proprietary data base system [iPipeline Agency Works] Follow up with pending cases Order medical records/medical exams when requested by carriers Review policies received to make sure they are correct Process all delivery requirements Follow up with carriers to ensure proper processing of all applications Run illustrations via Winflex Correspond daily with various agents (internal and external) regarding case status Additional office administration responsibilities Position Requirements 3 years of relevant life insurance experience Strong analytic skills Strong writing and verbal communication skills Good ability to work effectively with others Career oriented

The case manager will be assisting the GIVE social worker and Regional Administrator in providing services to perpetrators of gun violence in the city of Rochester. Services include but are not limited to comprehensive case management, resource referrals, in-person custom notifications, having the ability to navigate through different data bases and providing court advocacy to our participants. This position is responsible for adhering to all documentation and database requirements and accurately track work. This position attends custom notifications with Monroe County Probation and the RPD in order to make home visits to participants and their families when necessary. This role has the ability to flex their hours (when necessary) based off of the custom notification schedule the employee creates with RPD. Requirements (Education, Experience, Certification, Knowledge, Skill) Associates degree from an accredited university Experience working in the social services field 2+ years of experience working with individuals who have been or currently are involved in street and/or gang related activities. Position Responsibilities Work as an onsite case manager and member of the GIVE team in order to support participants of community gun-violence and their families. Manage the site's referral resource database and create relationships with local agencies and service providers Assist to navigate systems including providing court advocacy Attend custom notifications, and make home visits to participants and families when appropriate Maintain a sufficient caseload of clients at any given time Adhere to all documentation and database requirements and accurately track work Ability to work flexible hours (evenings and weekends) when necessary Any other relevant duties as assigned Working Conditions/Environment Requires frequent exposure to individuals displaying high-risk/violent behaviors. Requires frequent weekend and night hours. Requires frequent travel within the City of Rochester to different sites. Transportation Requirement Position requires automobile, driver's license, and insurance. Last Updated: 01/30/2025

Now Hiring: RN Case Manager - New York Work from home + local field travel Salary: $90,000 - $92,000 annually Quarterly Bonus Opportunities Free CEUs for licenses & certificates License & Certification Reimbursement We're looking for an RN with a passion for case management to join our team! RN degree required National Certification preferred (CCM, CRC, COHN, CRRC) Workers' Comp Case Management experience a plus Location Requirement Candidates must be based in one of these New York areas: Poughkeepsie, Newburgh, and Middletown. Your Impact: You'll provide effective case management services in a cost‑effective manner, delivering medical case management consistent with URAC standards, CMSA Standards of Practice, and Broadspire QA Guidelines. You'll support patients/employees receiving benefits under insurance lines including Workers' Compensation, Group Health, Liability, Disability, and Care Management. This is your chance to grow your career, earn great rewards, and enjoy true work-life balance. Apply today and make an impact in the community!

**Explore opportunities with Atrius Health,** part of the Optum family of businesses. We're an innovative health care leader and multi-specialty group practice, delivering an effective, connected system of care for adult and pediatric patients at 28 practice locations in eastern Massachusetts. Our entire team of providers (physicians, PA/NPs and ancillary clinicians) works collaboratively with a value-based philosophy within our group practice as well as with hospitals, rehab and nursing facilities. Be part of our vision to transform care and improve lives by building trust, understanding and shared decision-making with every patient. Join us and discover the meaning behind **Caring. Connecting. Growing together.** Position in this function is responsible for providing on-site transitional care coordination to ensure safe transitions of care and optimal communication between treating facility, Patient/Family and Atrius Health. Responsible for coordinating patient transitions from Hospital to home or other care settings, ensuring a smooth discharge process and continuity of care **Position Details:** + **Location** : Beth Israel Deaconess Medical Center located at 330 Brookline Ave. Boston, MA 02215 + **Department** : Case Management. + **Schedule:** 40HRS Weekly M-F 8:00am- 4:30pm **Primary Responsibilities:** + Provides direct referral source servicing at identified facility, building and enriching relationships, identifying needs, problem solving and meeting or exceeding expectations of external customers + Serves as an extension of the Atrius Health practice site, connecting with Atrius Health patients and/or families to bridge the Atrius Health practice to the patient + Conducts review of the medical record for Atrius Health adult medical or surgical hospitalized patients + Conducts initial assessment of patient within 24 - 48 hours (business days of admission) + Subsequent review/progress note at least every 7 days or accompanying a change in condition/plan + May provide educational and/or program material to the site facility staff in compliance with Atrius Health clinical initiatives, services and specialty programs + Performs needs assessments of patients/families for services including but not limited to primary care, specialty care visits, skilled homecare, palliative care, hospice care (including hospice residence), and/or skilled nursing facility, to ensure appropriateness of services and expedite transitions of care + Educates Atrius Health patients/families regarding provider relationships serviced through preferred homecare/SNF organizations + Assesses adult medical/surgical Atrius Health patients for risk of readmission, and communicates identified risks with transition of care, outpatient case manager and/or primary care team + Facilitates real-time review of contributing factors to readmission of patients and explores opportunities for acute care hospitalization (ACH) reduction + Accesses Atrius Health patient's Epic medical record to determine current program enrollment for continuation of care + Assesses patients admitted with Heart Failure (HF) or Chronic Obstructive Pulmonary Disease (COPD) for HTM/RPM and initiates referral to the appropriate program + Initiates a referral to the Atrius health heart failure program when appropriate + Collaborates with hospital-based case manager to facilitate advance care planning documents such as health care proxy or MOLST form + Facilitates communication between patient's hospital-based care team and practice based primary care team when needed or requested + Collaborates with transition of care team and hospital-based case manager to ensure post-hospital follow up visit is scheduled + Provides supportive patient/family education for targeted diagnoses including heart failure, diabetes, COPD to ensure optimal preparation for home discharge + Coordinates with the hospital-based case manager to facilitate regarding Atrius Health preferred provider networks + Seeks opportunities to improve communication and collaboration amongst all clinical partners in patient care treating facility and internal/external partners or provider + Collaborates and communicates with Manager and Atrius Health Case Manager to identify and address any issues or concerns + Documentation: Maintains accurate records of the discharge planning process in the patient's medical record for legal, regulatory, and billing purposes + Participates in service recovery as needed + Promotes problem identification, resolution to barriers in care delivery, efficiency, productivity and customer satisfaction + Builds relationships with physicians, referral sources, managed care and assigned facility(ies) + Provides information, resource materials and education to all providers and case managers and solicits feedback + Promotes Atrius Health specialty programs designed to meet the needs of patients, providers, and partners + Assists with other referral source account coverage as needed + Performs other duties as requested You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in. **Required Qualifications:** + Graduate of a State-approved school of nursing + Current, unrestricted, license to practice professional nursing in the Commonwealth of Massachusetts + American Heart Association Basic Life Support (BLS) + Electronic medical record (EMR) experience and/or aptitude to master the EMR based on other technology experience + Demonstrated proficiency using multiple software applications, including MS Office, EXCEL, Cloud based platforms and EPIC reporting workbench and dashboards + Demonstrated solid critical thinking, problem solving, interpersonal and patient interviewing skills + Demonstrated excellence in practice, documentation, and cost-effective care utilization Maintains high patient satisfaction + Demonstrated ability to interpret clinical information, assess the implication of treatment and develop and implement a plan of care + Demonstrated ability to interpret clinical information, apply UM criteria and health plan guidelines for decision making + Demonstrated ability to work effectively in a faced paced team environment **Preferred Qualifications:** + Bachelor of Science in Nursing (BSN) + Certification in Case Management (CCM) or CCM eligible preferred + 3+ years in utilization management or case management + 3+ years clinical experience with home health care experience or strong knowledge base in home health and hospice care **Other Requirements:** + Able to use all electronic tools and applications relevant to the performance of the duties of the position, including but not limited to phone, keyboard, computer and computer applications + Able to work in multiple locations and cover multiple primary care practices as needed + Performs all job functions in compliance with applicable federal, state, local and company policies and procedures Accesses only the minimum necessary protected health information (PHI) for the performance of job duties Actively protects the confidentiality and privacy of all protected health information they access in all its forms (written, verbal, and electronic, etc) taking reasonable precautions to prohibit unauthorized access Complies with all Atrius Health and departmental privacy policies, procedures and protocols Follows HIPAA privacy guidelines without deviation when handling protected health information **Working Conditions / Physical Demands** + Busy clinical environment with frequent deadlines and interruptions + May require some weekend or holiday coverage Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. In addition to your salary, we offer benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with us, you'll find a far-reaching choice of benefits and incentives. The hourly pay for this role will range from $40.21 to $74.74 per hour based on full-time employment. We comply with all minimum wage laws as applicable. _At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone-of every race, gender, sexuality, age, location and income-deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes - an enterprise priority reflected in our mission._ _OptumCare is an Equal Employment Opportunity employer under applicable law and qualified applicants will receive consideration for employment without regard to race, national origin, religion, age, color, sex, sexual orientation, gender identity, disability, or protected veteran status, or any other characteristic protected by local, state, or federal laws, rules, or regulations._ _OptumCare is a drug-free workplace. Candidates are required to pass a drug test before beginning employment._

covers Chelmsford/North Chelmsford/Lowell. 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. #P01

This position covers Boston/Suffolk County plus surrounding Middlesex County including Allston, Ashland, Auburndale, Babson Park, Belmont, Boston/East Boston, Brighton, Brookline, Brookline Village, Cambridge, Charlestown, Chestnut Hill, Dover, Framingham, Hyde Park, Jamaica Plain, Mattapan, Natick, Needham, Needham Heights, Newton, Newtonville, Nonatum, North Waltham, Waltham, Readville, Roslindale, Sherborn, Somerville, Waban, Watertown, Waverley, Wayland, Wellesely, West Newton, West Roxbury and Weston. 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. #P01 Not Ready to Apply? Join our Talent Community now!

This position covers Lynn and Saugus plus Chelsea, Essex, Everett, Hamilton, Lynnfield, Malden, Melrose, Nahant, Revere, South Hamilton, Swampscott and Winthrop. 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, shifting 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. #P01 Not Ready to Apply? Join our Talent Community now!

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. #P01

Up to $12,000 Sign On Bonus General Statement of Duties: As a lead member of the multi-disciplinary team, the nurse manager will ensure the health, safety and well-being of adults with disabilities and/or brain injuries living in a residential setting. The nurse manager will coordinate the health care needs of persons served and provide opportunities for social engagement, leisure time activities and skill building in a way that fosters growth, independence, dignity, choice and a meaningful life. Responsibilities: Follow the Department of Public Health's (DPH) Medication Administration Program (MAP) policies. Administer medications and treatments as prescribed, utilizing the agency's electronic health care record. Track and order durable medical equipment and other medical supplies on a weekly, bi-weekly or monthly basis. Provide direct care while supporting person served abilities and encouraging maximum level of independence and safety with ADL's. Provide physical health assessments to make critical, timely decisions. Document all assessments in the data tracking logs and medical records. Maintain ongoing professional communication, verbally and in writing, with all members of persons served team. Coordinate and transport individuals to medical appointments. Advocate for best health related outcomes. Collaborate with health care providers, and persons served team members, to develop and implement effective health care treatments and protocols. Encourage self-advocacy by persons served at appointments and engage individuals in developing their treatment plan. Ensure individuals' nutritional needs are met based on personal preferences and according to prescribed diet. Provide support with preparation and eating as necessary. Organize, assess, and appropriately utilize data, daily progress notes and staff log notes. Liaison with hospitals and rehabilitation centers to ensure safe admissions and discharges. Ensure Positive Behavior Supports (PBS), BAMSI's framework for delivering clinical services, are implemented by offering choices and preferred routines, meeting needs, supporting individual's goals, modeling pro-social behaviors, and maintaining professional boundaries. Use communication systems suited to persons served needs, and promote independence through the use of assistive technology and cognitive supports. Collaborate with the program manager to assist in planning safe activities, connecting and integrating individuals into their communities through social, spiritual, and recreational opportunities. Provide necessary support to ensure safety while in the community. Maintain knowledge of ongoing program issues and communicate issues to supervisor or designee. Adhere to submission deadlines for ISP related documents and incident reports based on funding source and agency timelines. Review medical records and physician orders to ensure program compliance, updating information as needed. Provide oversight of daily operations in the absence of supervisor or designee, as requested. Execute duties to reflect reasonable safety standards. Universal/standard precautions must be utilized and training obtained in areas that constitute risk. Assist with interviewing, hiring, and supervising nursing staff. Collaborate with the program manager to provide guidance for direct care and nursing staff, including implementing recognition for staff achievements and the progressive disciplinary process. Facilitate staff meetings and on-going program-specific medical trainings on diagnosis, protocols, safe care, and other heath related topics. Work in collaboration with Relief and Per Diem staff, and their supervisors to provide training, supervision, and job development needs that arise. Attend mandatory trainings and meetings. Disseminate training materials at the program level. Perform other related duties as needed or as assigned by supervisor or designee. Provide coverage at day habilitation programs or other residential programs as needed. Provide 24 hour on-call, on a rotating basis, to ensure nursing coverage and optimal service delivery. Rotate schedule to work holidays as needed. Perform duties to reflect agency policies and procedures. Qualifications : Licensed Practical Nurse or Registered Nurse in the Commonwealth of Massachusetts 3 years of nursing experience prior supervisory experience preferred CPR certification required Knowledge of the theories, methods, procedures, and practices of nursing care. Must possess a valid driver's license in state of residence and satisfactory driving record Basic computer literacy, including the ability to record data, use electronic time and attendance software, receive and send email, is required. Ability to lift, transfer, push/pull, maneuver, and reposition 25 pounds. Ability to reach, bend, stand, sit and walk; perform fine motor activities. Work effectively in a moderate to occasionally loud work environment. BAMSI is a 501(c) 3 nonprofit organization founded in Brockton, Massachusetts, with a vision of driving change and creating equal opportunities for individuals with developmental disabilities and mental and behavioral health challenges. Brockton Area Multi-Services, Inc. (BAMSI) was incorporated on March 21, 1975 as South Shore Multi-Services Inc., under Chapter 180 of the Massachusetts General Laws, as a not-for-profit human service organization. On July 9, 1975, it changed its name to Brockton Area Multi-Services, Inc. It was formed for the development, coordination, and delivery of integrated human service programs, and according to its website, its mission is “to empower people and enrich their lives, through compassionate support and diverse services, one individual, one family a time.” BAMSI employees up to 2,000 people and operates adult, child, and family services, assisting approximately 30,000 individuals each year in Worcester, Middlesex, Norfolk, Bristol, and Plymouth Counties. BAMSI is committed to Diversity, Equity, Inclusion, Justice, and Access for all; to creating a holistic system of care that meets people where they are; and abolishing the stigmas surrounding mental illness, disability, and addiction. We strive to offer valuable benefits that promote a healthy work/life balance and add value to our employees' lives. Our comprehensive benefits include: Generous Time Off Package 4 weeks combined vacation , personal and cultural holiday 12 paid holidays 2 weeks Sick Time Highly Specialized Paid Trainings including opportunity to earn CEUs Health and Dental Insurance Life, Short Term and Long Term Disability Insurance 403B plan with discretionary match Wellness Activities Employee Assistance Program Career Development Opportunities

**Join Us in Shaping the Future of Health Care** At MVP Health Care, we're on a mission to create a healthier future for everyone. That means embracing innovation, championing equity, and continuously improving how we serve our communities. Our team is powered by people who are curious, humble, and committed to making a difference-every interaction, every day. We've been putting people first for over 40 years, offering high-quality health plans across New York and Vermont and partnering with forward-thinking organizations to deliver more personalized, equitable, and accessible care. As a not-for-profit, we invest in what matters most: our customers, our communities, and our team. **What's in it for you:** + Growth opportunities to uplevel your career + A people-centric culture embracing and celebrating diverse perspectives, backgrounds, and experiences within our team + Competitive compensation and comprehensive benefits focused on well-being + An opportunity to shape the future of health care by joining a team recognized as a **Best Place to Work For in the NY Capital District** , one of **the Best Companies to Work For in New York** , and an **Inclusive Workplace** . You'll contribute to our humble pursuit of excellence by bringing curiosity to spark innovation, humility to collaborate as a team, and a deep commitment to being the difference for our customers. Your role will reflect our shared goal of enhancing health care delivery and building healthier, more vibrant communities. **Qualifications you'll bring:** + Current New York State license as an LPN or Registered Nurse preferred + Experience in review of clinical documentation and medical records. + Previous HEDIS Measure subject matter expertise. + Excellent clinical assessment and decision-making skills as demonstrated by the ability to readily abstract pertinent clinical information from the review of a wide range of medical records. + Must meet pre-established thresholds for clinical review post-training testing. + Ability to maintains the confidentiality of providers/practitioners, and members. + Curiosity to foster innovation and pave the way for growth + Humility to play as a team + Commitment to being the difference for our customers in every interaction **Your key responsibilities:** + Support annual clinical quality review and medical record abstraction for MVP's regulatory required medical record reviews for the following measures: + Controlling High Blood Pressure (CBP) + Cervical Cancer Screening (CCS) + Childhood Immunization Status (CIS) + Comprehensive Diabetes Care (CDC) + Care for Older Adults (COA) + Prenatal and Postpartum Care (PPC) + Transitions of Care (TRC) + Weight Assessment and Counseling for Children and Adolescents (WCC) + Review training materials and measure criteria for HEDIS Vendor + Knowledge and use of HEDIS Vendor Reporting package + Support the Quality team in member and provider outreach to improve overall Quality performance + Utilize remote access to obtain medical records + Contribute to our humble pursuit of excellence by performing various responsibilities that may arise, reflecting our collective goal of enhancing healthcare delivery and being the difference for the customer. **Where you'll be:** Location: Virtual within New York State **Pay Transparency** MVP Health Care is committed to providing competitive employee compensation and benefits packages. The base pay range provided for this role reflects our good faith compensation estimate at the time of posting. MVP adheres to pay transparency nondiscrimination principles. Specific employment offers and associated compensation will be extended individually based on several factors, including but not limited to geographic location; relevant experience, education, and training; and the nature of and demand for the role. We do not request current or historical salary information from candidates. $0.00-$0.00 **MVP's Inclusion Statement** At MVP Health Care, we believe creating healthier communities begins with nurturing a healthy workplace. As an organization, we strive to create space for individuals from diverse backgrounds and all walks of life to have a voice and thrive. Our shared curiosity and connectedness make us stronger, and our unique perspectives are catalysts for creativity and collaboration. MVP is an equal opportunity employer and recruits, employs, trains, compensates, and promotes without discrimination based on race, color, creed, national origin, citizenship, ethnicity, ancestry, sex, gender identity, gender expression, religion, age, marital status, personal appearance, sexual orientation, family responsibilities, familial status, physical or mental disability, handicapping condition, medical condition, pregnancy status, predisposing genetic characteristics or information, domestic violence victim status, political affiliation, military or veteran status, Vietnam-era or special disabled Veteran or other legally protected classifications. To support a safe, drug-free workplace, pre-employment criminal background checks and drug testing are part of our hiring process. If you require accommodations during the application process due to a disability, please contact our Talent team at ******************** .

Join Us in Shaping the Future of Health CareAt MVP Health Care, we're on a mission to create a healthier future for everyone. That means embracing innovation, championing equity, and continuously improving how we serve our communities. Our team is powered by people who are curious, humble, and committed to making a difference-every interaction, every day. We've been putting people first for over 40 years, offering high-quality health plans across New York and Vermont and partnering with forward-thinking organizations to deliver more personalized, equitable, and accessible care. As a not-for-profit, we invest in what matters most: our customers, our communities, and our team. What's in it for you: Growth opportunities to uplevel your career A people-centric culture embracing and celebrating diverse perspectives, backgrounds, and experiences within our team Competitive compensation and comprehensive benefits focused on well-being An opportunity to shape the future of health care by joining a team recognized as a Best Place to Work For in the NY Capital District, one of the Best Companies to Work For in New York, and an Inclusive Workplace. You'll contribute to our humble pursuit of excellence by bringing curiosity to spark innovation, humility to collaborate as a team, and a deep commitment to being the difference for our customers. Your role will reflect our shared goal of enhancing health care delivery and building healthier, more vibrant communities.Qualifications you'll bring: Current New York State license as an LPN or Registered Nurse preferred Experience in review of clinical documentation and medical records. Previous HEDIS Measure subject matter expertise. Excellent clinical assessment and decision-making skills as demonstrated by the ability to readily abstract pertinent clinical information from the review of a wide range of medical records. Must meet pre-established thresholds for clinical review post-training testing. Ability to maintains the confidentiality of providers/practitioners, and members. Curiosity to foster innovation and pave the way for growth Humility to play as a team Commitment to being the difference for our customers in every interaction Your key responsibilities: Support annual clinical quality review and medical record abstraction for MVP's regulatory required medical record reviews for the following measures: Controlling High Blood Pressure (CBP) Cervical Cancer Screening (CCS) Childhood Immunization Status (CIS) Comprehensive Diabetes Care (CDC) Care for Older Adults (COA) Prenatal and Postpartum Care (PPC) Transitions of Care (TRC) Weight Assessment and Counseling for Children and Adolescents (WCC) Review training materials and measure criteria for HEDIS Vendor Knowledge and use of HEDIS Vendor Reporting package Support the Quality team in member and provider outreach to improve overall Quality performance Utilize remote access to obtain medical records Contribute to our humble pursuit of excellence by performing various responsibilities that may arise, reflecting our collective goal of enhancing healthcare delivery and being the difference for the customer. Where you'll be: Location: Virtual within New York State Pay TransparencyMVP Health Care is committed to providing competitive employee compensation and benefits packages. The base pay range provided for this role reflects our good faith compensation estimate at the time of posting. MVP adheres to pay transparency nondiscrimination principles. Specific employment offers and associated compensation will be extended individually based on several factors, including but not limited to geographic location; relevant experience, education, and training; and the nature of and demand for the role.We do not request current or historical salary information from candidates. $0.00-$0.00MVP's Inclusion StatementAt MVP Health Care, we believe creating healthier communities begins with nurturing a healthy workplace. As an organization, we strive to create space for individuals from diverse backgrounds and all walks of life to have a voice and thrive. Our shared curiosity and connectedness make us stronger, and our unique perspectives are catalysts for creativity and collaboration.MVP is an equal opportunity employer and recruits, employs, trains, compensates, and promotes without discrimination based on race, color, creed, national origin, citizenship, ethnicity, ancestry, sex, gender identity, gender expression, religion, age, marital status, personal appearance, sexual orientation, family responsibilities, familial status, physical or mental disability, handicapping condition, medical condition, pregnancy status, predisposing genetic characteristics or information, domestic violence victim status, political affiliation, military or veteran status, Vietnam-era or special disabled Veteran or other legally protected classifications.To support a safe, drug-free workplace, pre-employment criminal background checks and drug testing are part of our hiring process. If you require accommodations during the application process due to a disability, please contact our Talent team at ...@mvphealthcare.com .