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Care Services Coordinator (Navigator) - Growing Medicare/Elder Services Program!

Company Name:
Fallon Health
About Fallon Community Health Plan:
Founded in 1977, Fallon Community Health Plan is a nationally recognized, not-for-profit health care services organization. From traditional health insurance products available throughout Massachusetts for all populations, to innovative health care programs and services for independent seniors, FCHP supports the diverse and changing needs of all those it serves. FCHP has consistently ranked among the nation's top health plans, and is the only health plan in Massachusetts to have been awarded "Excellent" Accreditation by the National Committee for Quality Assurance for its HMO, Medicare Advantage and Medicaid products. For more information, visit .
About NaviCare:
NaviCare HMO is a Medicare Advantage Plan and Senior Care Options program from Fallon Community Health Plan. Medicare Advantage contracts between the federal government and managed care organizations. _NaviCare HMO combines all the benefits that are covered by Medicare and MassHealth Standard into one program. Navicare HMO also includes Medicare Part D. _

Position Overview:
_ _
The Navigator helps the primary care provider, nurse case manager, geriatric support services coordinator, long-term care facility liaison and other providers know at all times what is occurring with the Enrollee and their status. Responsibilities include: placing referrals and following up to ensure services are in place as per the individual care plan; coordinating and documenting PCT meetings, facilitating data transfers and ensuring the Centralized Enrollee Record (CER) and FCHP Core System is up to date. The Navigator works closely with the Nurse Case Manager. The Navigator refers to the Nurse Case Manager/PCP whenever clinical decision making is required. In order to effectively advocate for Enrollee needs, the Navigator makes in home visits/long term care facility visits with/without the Nurse Case Manager/GSSC to fully understand an Enrollee care needs.
The Navigator seeks to establish a relationship with the Enrollee/caregiver(s)/facilities to better ensure ongoing service provision and care coordination, consistent with the member specific care plan.
Outreaches to all new NaviCare Program Enrollees within designated periods from start date of enrollment via the telephone and/or in person. Introduces self/role and ensures the Enrollee/caregiver/facility is orientated to the NaviCare Program and benefits
Gathers data from the Enrollee's medical record in areas such as preventative health screenings, working with the Enrollee and Primary Care Provider to ensure the Enrollee receives health care according to established guidelines
Responds to Enrollee/caregiver/Facility questions or concerns about their health/benefits
Makes in home/institutional/office visits as need be to introduce self/role and ensure the Enrollee/caregiver/facility is orientated to the NaviCare Program and benefits
Coordinates Enrollee visits to the Primary Care Physician (PCP) and other clinicians as appropriate based upon clinical need and program guidelines, including but not limited to ensuring adequate transportation
Follows up with the Enrollee to ensure they were seen by the PCP and other clinician appointments and obtains the clinical summaries from the appointment and scans into the CER per Department process
Is a member of the Enrollee's Primary Care Team (PCT)
Coordinates/schedules PCT meetings on a regular basis depending upon Enrollee needs according to Department guidelines
Ensures PCT meeting summaries are entered/scanned into the CER per Department process
Coordinates and ensures members of the PCT (i.e. Geriatric Support Services Coordinator or Long Term Care Facility Liaison, NaviCare Program Case Manager, NaviCare Program Behavioral Health Clinician and others) are involved and knowledgeable about the Enrollee status based upon Enrollee need and PCP/PCT direction at all times
Ensures authorizations for NaviCare Program specific covered services are entered into the CER and the FCHP Core System as appropriate based upon Department processes
Ensures the Enrollee's Individual Plan of Care (IPC) is up to date in conjunction with plans developed by members of the Primary Care Team/Primary Care Physician
Ensures the Enrollee is in agreement with their ICP and documents Enrollee approval of such in the CER
Ensures the Nurse Case Manager follows up with Enrollees after an emergent/urgent care need and/or care transition such as a hospitalization or skilled nursing facility admission
Works with the emergent/urgent/acutecare/skilled nursing facility provider to obtain discharge documentation and ensures information is entered/scanned into the CER per Department process and shared with all members of the PCT
If any Enrollee assessment or reassessment is positive for new risk factors, the Navigator in conjunction with the Nurse Case Manager facilitates a PCT meeting, updates the care plan as appropriate, and initiates the development of a support system to avert further deterioration. Such support system may include:
Arranging an urgent home visit within 24 hours of the discovery to more fully assess the situation
Arranging an urgent office visit with the provision of transportation if needed.
Responsible for updating and maintaining accuracy of panel access data base lists - processes according to Department guidelines
For those with a panel of Enrollees residing in Long Term Care, obtains MDS forms from the Facilities as per Department processes and ensures the data is integrated into the Centralized Enrollee Record
Uses the appropriate FCHP IT application(s) including the CER to document all case activity and facilitate appropriate communication between The PCT Team members
Identifies and shares best practices and innovative care management strategies with the team
Resolves conflicts among participants in the care planning process
Creates contingency plans for each step of the process to anticipate treatment and service complications, while ensuring that the Enrollee attains pre-determined outcomes
Supports department colleagues, covering and assuming changes in assignment as assigned by Supervisor/designee
Strictly observes HIPPA regulations and the FCHP policies regarding confidentiality of member information
Performs other responsibilities as assigned by the Supervisor/designee, including but not limited to covering the NaviCare Enrollee Service ACD line
Education: College degree (BA/BS in Health Services or Social Work) preferred
License: Current MA Driver's License
Experience: 1-3 years job experience in a medical related field or with a healthcare payor company. Experience in a healthcare payor company a plus.
Experience caring for the geriatric population.
Experience with telephonic and in person interviewing skills
Date: 2014-07-24
Country: US
State: MA
City: Worcester
Category: Care Coordination

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