Care Coordinator / Navigator - Cape Cod - Fallon Health : Job Details

The Navigator is an integral part of an interdisciplinary team focused on care coordination, care management, and improving access to and quality of care for Fallon members. The Navigator partners with Fallon Health Care Team staff and other providers to always communicate what is occurring with the member and their status. The Navigator seeks to establish telephonic and face to face (depending upon product and circumstance) relationships with the member/caregivers and provider partners to better ensure ongoing service provision and care coordination, consistent with the member specific care plan. To effectively advocate for member needs, the Navigator may make in home or facility visits (depending upon the product and circumstances) with or without other Care Team members to fully understand a member's care needs.

Responsibilities include but are not limited to:

• Utilizes an ACD line to support department and incoming/outgoing calls with the goal of first call resolution with each interaction
• Conducting telephonic and may conduct face-to-face member visits to assess members utilizing TruCare Assessment Tools
• Establishing and developing effective working relationships with community partners such as housing staff, adult day health care staff, assisted living staff, group adult foster and adult foster care staff, rest home staff, long term care facilities and other providers including primary care providers with the goal to facilitate member specific communication, represent Fallon Health in a positive and effective manner, and work to grow membership in the various Fallon Health products as applicable
• Educating members/PRAs about their product specific benefits and how to access often times facilitating and coordinating such
• Help members to ensure physician office visits are scheduled and attended
• Places referrals and following up to ensure services are in place as per the individual care plan and developing a care plan in conjunction with the Care Team, preparing and sending member specific care plans per process
• Performs care coordination for members adhering to contact and duration frequencies documenting all activities in the TruCare system utilizing the appropriate assessment and/or note type following Clinical Integration Documentation Policy
• Contacts members to resolve gaps in care including but not limited to: PCP assignment, PCP visits, preventative screenings, vaccination reminders, and other initiatives as assigned
• Help members obtain access to care including but not limited to working with providers to arrange medical and behavioral health appointments and following up with members afterwards to ensure they attended, if not determine barriers, and work to have members attend appointments as required
• If working on the NaviCare Member Population: Facilitates transportation to medical, behavioral health, and social appointments by educating the member about the process to request transportation and/or working to assist the member to obtain such
• If working on the ACO Member Population: Facilitates transportation to medical and behavioral health appointments by completing the MassHealth PT-1 process on behalf of the member/provider
• Educates members and assists members to obtain community benefits including but not limited to food through the EBT system, fuel assistance and other community programs and services such as WIC
• Screens members for social determinants and service needs and refers members to Clinical Team members and Partners for intervention based upon criteria and processes
• If working on the ACO or Commercial Products and depending upon process: May contact maternity members after hospital discharge to facilitate delivery of items as part of the 'Oh Baby' program and work with Nurse Case Managers to coordinate after care needs
• The Navigator refers to the Nurse Case Manager/PCP whenever clinical decision making is required