Fallon Health

Account Executive

• Manage referral sources and drive enrollments for the Summit ElderCare PACE program
• Conduct community outreach and explain program details to prospects

Account Executive, Healthcare

Manager

• 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.

Senior Nurse Case Manager – Senior Care Options

• Creates productive and collaborative relationships with internal and external referral sources
• Works with referral sources to obtain leads and progress them through the enrollment process
• Participates in community outreach activities
• Travels to meet with Summit ElderCare prospects in their homes
• Explains the Summit ElderCare PACE program clearly to prospects
• Conducts presentations on the Summit ElderCare PACE program
• Tours both professionals and prospects at the Summit ElderCare PACE sites
• Develops and implements a customized Territory Development Plan
• Works collaboratively with Summit ElderCare enrollment team
• Shows accountability and follows up with prospects
• Generates sufficient Summit ElderCare enrollment referrals
• Timely and accurately documents sales activities in the department’s CRM application.

Account Executive, Sales – Healthcare

Software Engineer

• Design, develop, and maintain applications using .NET (C#, ASP.NET, .NET Core).
• Build and customize solutions within Microsoft Dynamics 365 and Power Platform (Power Apps, Power Automate, Power BI).
• Collaborate with business analysts and stakeholders to gather requirements and translate them into technical solutions.
• Integrate applications with internal and external systems using APIs, web services, and data connectors.
• Participate in code reviews, testing, and deployment activities using modern engineering principles.
• Troubleshoot and resolve technical issues and provide ongoing support.
• Document technical specifications, processes, and procedures.
• Participation in the integration of multiple core systems including Sales, Admin, Member Services, Medical Record Management, Claims, and Finance.
• Develop and implement a strategic plan to migrate .NET applications to the Power Automate platform.
• Migrate custom applications from On-Premise to cloud-based solutions.

Application Developer III – Dynamics Experience

• Provide telephonic assessments and case management for a member panel
• Conduct in-home face to face visits for onboarding new enrollees and reassessing members
• Perform medication reconciliations
• Complete NaviCare Program Assessment Tools and Minimum Data Set Home Care (MDS HC) Form when a member’s medical/functional status changes
• Educate members about the management of current disease processes and medication regimen
• Collaborate with appropriate team members to ensure health education/disease management information is provided
• Develop and foster relationships with members, family, caregivers, providers to ensure good collaboration
• Manage ACO members in conjunction with the Navigator, Social Care Managers, ACO Partners, Community Partners, Behavioral Health Partners
• Attend care plan meetings with providers and office staff

SCO Nurse Case Manager – Khmer Preferred

• Design, develop, and maintain applications using .NET (C#, ASP.NET, .NET Core).
• Build and customize solutions within Microsoft Dynamics 365 and Power Platform (Power Apps, Power Automate, Power BI).
• Collaborate with business analysts and stakeholders to gather requirements and translate them into technical solutions.
• Integrate applications with internal and external systems using APIs, web services, and data connectors.
• Participate in code reviews, testing, and deployment activities using modern engineering principles.
• Troubleshoot and resolve technical issues and provide ongoing support.
• Document technical specifications, processes, and procedures.
• Participate in the integration of multiple core systems including Sales, Admin, Member Services, Medical Record Management, Claims, and Finance.
• Develop and implement a strategic plan to migrate .NET applications to the Power Automate platform.
• Migrate custom applications from On-Premise to cloud-based solutions.

Application Developer – Growing Healthcare Organization

Call Center Representative

• Address member and provider inquiries received through Fallon Health's 1-800 numbers
• Provide direction on Plan policies, procedures, and benefits
• Act as primary liaison for members to obtain information or support
• Fully understand member/provider needs and take action within corporate/department policies to satisfy inquiries
• Clear and concise documentation of call detail for tracking
• Identify and communicate trends indicative of enterprise service issues
• Escalate member/provider concerns and servicing issues
• Execute corporate and department policies/practices
• Complete approximately 8-9 weeks of on-site training in Worcester, MA before transitioning to remote work

Call Center Service Representative

• Telephonically assesses and case manages a member panel
• May conduct in home face to face visits for onboarding new enrollees and reassessing members
• Establishes telephonic and/or face to face relationships with the member/caregiver(s) to ensure ongoing service provision and care coordination
• Develops and implements individualized, coordinated care plans in collaboration with members, Clinical Integration team, Primary Care Providers, Specialists and community partners
• Performs medication reconciliations
• Performs Care Transitions Assessments per Program and product line processes
• Completes NaviCare Program Assessment Tools and Minimum Data Set Home Care (MDS HC) Form when indicated
• Maintains up to date knowledge of Program and product line benefits, Plan Evidence of Coverage details, and department policies and processes
• Serves as an advocate for members and facilitates access to community resources when needs are not covered by Fallon Health
• Authorizes and coordinates healthcare services in compliance with documented care plan goals and regulatory standards
• Assesses member disease and medication management knowledge and provides education to increase self-management
• Collaborates with interdisciplinary team to identify and address high risk members and to provide disease management information
• Educates members on preventative screenings and other health care procedures according to protocols
• Ensures members/PRAs participate in development and approval of their care plans
• Strictly observes HIPAA regulations and Fallon Health confidentiality policies
• Provides culturally appropriate care coordination, working with interpreters and communication in appropriate languages
• Manages NaviCare and ACO members in conjunction with Navigators, Behavioral Health Case Managers, Social Care Managers, and community partners
• Monitors progression of member goals and care plan goals and provides feedback to care team
• Works collaboratively with Fallon Health Pharmacist for medication review referrals
• Develops and fosters relationships with members, family, caregivers, vendors and providers to streamline care
• May attend and lead in-person care plan meetings with providers and office staff
• Completes Program Assessments, Notes, Screenings, and Care Plans in the Centralized Enrollee Record according to regulatory requirements
• Supports Quality and Ad-Hoc campaigns and completes other responsibilities as assigned by Manager/designee