Nurse Case Manager - Cancer Care/End of Life RN Needed - Great Managed Care Org!

Company Name:
Fallon Health
About Fallon Health:
Founded in 1977, Fallon Health is a leading health care services organization that supports the diverse and changing needs of those we serve. In addition to offering innovative health insurance solutions and a variety of Medicaid and Medicare products, we excel in creating unique health care programs and services that provide coordinated, integrated care for seniors and individuals with complex health needs. Fallon 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 .
Position Overview:
The Nurse Case manager (NCM) proactively identifies and assesses high-risk members, with complex conditions, and develops and implements an individualized, coordinated care plan, in collaboration with the Primary Care Physician, to ensure a cost effective, quality outcome, focused in the ambulatory setting. This position will be specifically working with members with cancer throughout all our product lines. The NCM assists the member in attaining and/or maintaining an optimal functional status. The NCM is responsible for all activities related to:
Working directly with members, their physicians, and other care managers to assess the needs of high-risk members and develops customized, proactive care plans resulting in the member attaining and/or maintaining an optimal functional status. Performs medication reconciliations.
Authorizing services, coordinating care, ensuring timeliness and coordinating healthcare services, in compliance with documented care plan goals and objectives, and Department and regulatory standards, seeking supplemental benefit and/or community services when appropriate or needed. Refers to and works with Department Social Workers on member specific care plans.
Working independently and collaboratively as a facilitator with other members of the health care team to ensure that members receive quality, cost-appropriate care.
In conjunction with both internal and external customers, the NCM promotes and works towards achieving the goals and objectives of the Care Services Department and Fallon Community Health Plan.
Effectively manages all outpatient care/case management functions to ensure FCHP members receive high quality, cost effective care. Performs an advocacy and a 'navigator' role assisting the member to 'navigate' the health care system.
Screens member enrollment data, claims data, urgent and emergency room utilization, acute inpatient notes, referrals from providers and vendors, and other appropriate data to initiate a member assessment.
Verifies member enrollment data, verifying eligibility, benefit plan coverage, and network affiliation.
Telephonically contacts members/families/caregivers and:
Introduces the member to the program through a telephone call or letter correspondence.
Ensures verbal consent of participation is obtained from the member.
Conducts screenings and assessments on members that meet the criteria for entry into the Case management Program.
Initiates a home visit through contracted home health care vendors for those members in need of an on-site assessment in order to develop a comprehensive care plan.
Facilitates the development and implementation of an individualized care plan, in collaboration with the Primary Care Physician, incorporating assessment, education, resource planning and coordination of services for members accepted into the Outpatient Care Services program.
Communicates with member/family/caregiver(s) in accordance with frequency of Case Management contact guidelines.
Incrementally monitors the effectiveness of the care plan with defined, measurable goals and objectives and cost-benefit documentation as applicable.
Performs medication reconciliation at each member call.
Contacts the member's physician(s) by communicating any medication issues or other clinical issues or needs needing physician awareness and direction. Updates the member/family/caregiver(s) as required.
Identifies, aligns, and utilizes health plan and community resources (such as education, support groups, and community providers) that impact high-risk care.
Streamlines 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.
Collaborates with FCHP Inpatient Nurse Care Specialists to facilitate a safe, timely discharge from the inpatient setting.
Creates contingency plans for each step of the process to anticipate treatment and service complications, while ensuring that the member attains pre-determined outcomes.
Uses the appropriate FCHP IT application(s) to document all case activity and facilitate appropriate communication regarding Case Management members.
Issues letters according to the Case Management policies and procedures.
Initiates case conferences with member/family/caregiver(s) as necessary and coordinates the participation of appropriate interdisciplinary team members.
Participates in as needed case conferences with the leadership team and/or Medical Reviewer to discuss patient issues and/or concerns. Organizes and presents complex medical cases in a clear and concise manner both oral and written.
Refers appropriate cases to the Medical Reviewer for member conference with the PCP regarding care issues (e.g. treatment modality, appropriate utilization of services, quality/risk issues).
Maintains documentation of individual care management plans, interventions, cost/benefit analyses, and other statistics as needed, to demonstrate the clinical quality outcomes and cost-effective financial impact of care management.
Identifies and shares best practices and innovative care/case management strategies with the team.
Ensures ad hoc contracts are in place for non-contracted services working in conjunction with FCHP Network Development team.
Resolves conflicts among participants in the care planning process.
Participates in collaborative care initiatives as assigned
Supports department colleagues, covering and assuming changes in assignment as assigned by Supervisor/Manager of Case Management Outpatient Care Services.
Strictly observes HIPPA regulations and the FCHP policies regarding confidentiality of member information.
Performs other responsibilities as assigned by the Supervisor/Manager of Case Management.
Education: Graduate from an accredited school of nursing mandatory and a Bachelor's (or advanced) degree in nursing or a health care related field preferred.
License: Active licensure as a Registered Nurse in Massachusetts
Certification: Certification in Case Management or a Oncology Certification Management a plus
Experience: A minimum of three to five years clinical experience as a Registered Nurse managing chronically ill high-risk patients. Oncology Experience or End of Life Experience is Required. Home Health Care and/or Physician office experience a plus. One year experience as a case manager in a managed care setting a plus.
Date: 2014-08-29
Country: US
State: MA
City: Worcester
Category: Case Management

Don't Be Fooled

The fraudster will send a check to the victim who has accepted a job. The check can be for multiple reasons such as signing bonus, supplies, etc. The victim will be instructed to deposit the check and use the money for any of these reasons and then instructed to send the remaining funds to the fraudster. The check will bounce and the victim is left responsible.