Senior Patient Accounting Specialist
INTEGRIS Health
Senior Care Options Nurse Case Manager, Spanish Preferred
Fallon Health
full-time
Posted on:
Origin: • 🇺🇸 United States • Massachusetts
Visit company websiteJob Level
Senior
About the role
- 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
Requirements
- Graduate from an accredited school of nursing mandatory
- Bachelors (or advanced) degree in nursing or a health care related field preferred
- Active, unrestricted license as a Registered Nurse in Massachusetts
- Certification in Case Management strongly desired
- Satisfactory Criminal Offender Record Information (CORI) results and reliable transportation
- 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
- 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
- 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
