Medicare/Community Care Nurse Case Manager

About the role

Fallon Health is a mission-driven organization that delivers equitable, high-quality, coordinated care to Medicare, Medicaid, and PACE members. The Nurse Case Manager (NCM) partners with an interdisciplinary team to assess needs, coordinate services, and improve health outcomes through telephonic outreach, care planning, and advocacy. The role emphasizes complex case management, reducing readmissions, addressing social determinants of health, and aligning members with community resources.

Responsibilities

• Telephonically assess and manage a member panel, including cold calls to members with potential needs
• Conduct regular assessments using motivational interviewing and culturally sensitive strategies to identify clinical/functional status and special conditions
• Develop and implement individualized, coordinated care plans in collaboration with members, providers, and community resources
• Perform medication reconciliations and care transitions assessments using tools like PointClickCare
• Assess readmission risk and participate in multidisciplinary rounds
• Close HEDIS gaps in care by ensuring preventive health metrics are complete
• Maintain up-to-date knowledge of Medicare and Community Care benefit structures, Evidence of Coverage details, and department policies
• Educate members and providers on rights, benefits, and quality gaps; advocate for access to covered and non-covered services
• Coordinate healthcare services, authorize care, and ensure timeliness in compliance with documented care plan goals
• Assess and teach members/caregivers about disease management, medication regimens, and self-management
• Identify and refer members to other Fallon Health products (e.g., NaviCare, ACO, Summit) as appropriate
• Collaborate with interdisciplinary teams to identify and address high-risk members
• Educate members on preventive screenings, vaccines, and healthcare procedures per established protocols
• Identify and address social determinants of health (SDOH) by partnering with community agencies for services like transportation and food programs
• Manage members at risk for medication non-compliance in coordination with the Fallon pharmacy team
• Observe HIPAA and Fallon Health confidentiality policies
• Support quality initiatives and ad-hoc campaigns
• Provide culturally appropriate care coordination, including working with interpreters and providing translated materials
• Develop member-centered care plans with the member/authorized representative(s)
• Monitor progression of member and care plan goals; collaborate with care team members to coordinate care
• Foster relationships with members, family, caregivers, PRAs, vendors, and providers to streamline care
• Act as an advocate to ensure medical needs are met effectively and cost-efficiently
• Participate in clinical rounds and update providers on critical health issues
• Educate members on quality gaps in care and advocate for member needs with providers
• Familiarize with multiple provider and facility electronic medical records to review member records
• Complete program assessments, notes, screenings, and care plans in the Centralized Enrollee Record per regulatory requirements
• Ensure compliance with HEDIS and Medicare 5 Star measure processes; educate members and perform outreach
• Prepare members for CAHPS surveys by understanding relevant questions
• Serve as a subject matter expert in complex case management to meet NCQA standards

Education & Qualifications

• Graduate from an accredited school of nursing (mandatory)
• Bachelor’s or advanced degree in nursing or a healthcare-related field (preferred)
• Active, unrestricted Massachusetts Registered Nurse license
• Certification in Case Management (strongly desired)
• Satisfactory Criminal Offender Record Information (CORI) results
• Reliable transportation

Experience

• 1+ years of clinical experience as a Registered Nurse managing chronically ill members or in a coordinated care program (required)
• Understanding of hospitalization experiences and post-discharge needs (required)
• Experience with telephonic interviewing and working with diverse, non-English speaking populations (required)
• Home health care experience (preferred)
• Effective case management and care coordination skills; ability to assess ADLs/IADLs and develop care plans (preferred)
• Familiarity with NCQA, CAHPS, and Stars/HEDIS metrics (preferred)

Performance Requirements

• Excellent communication and interpersonal skills with members and providers via phone and in person
• Exceptional customer service and willingness to resolve issues promptly
• Strong organizational skills and ability to multitask
• Adherence to policy and process requirements
• Independent learning skills; ability to use self-study, mentoring, classroom, and group education
• Collaborative team partner; respects all roles and contributes positively
• Willingness to learn insurance regulatory and accreditation requirements
• Proficiency with Microsoft Office (Excel, Outlook, Word) and Excel spreadsheets, including pivot tables
• Accurate and timely data entry
• Knowledge of community resources, levels of care, and regulatory guidelines
• Ability to adapt to changing business needs; innovative and creative problem solver

Competencies

• Commitment to Fallon Health’s Mission, Values, and Vision
• Problem Solving: Asks good questions; demonstrates critical thinking and looks beyond the obvious
• Adaptability: Handles challenges confidently; adjusts to shifting priorities, ambiguity, and rapid change
• Written Communication: Writes clearly and succinctly in a variety of contexts