Fallon Health is a company that cares. We prioritize our members--always-making sure they get the care they need and deserve. Founded in 1977 in Worcester, Massachusetts, we deliver equitable, high-quality coordinated care and are continually rated among the nation's top health plans for member experience, service, and clinical quality.
Fallon Health's Summit ElderCare is a Program of All-Inclusive Care for the ElderlyPACE for short. PACE, an alternative to nursing home care, is a program that helps people 55 and older continue living safely at home. At Fallon Health, we believe our individual differences, life experiences, knowledge, self-expression and unique capabilities allow us to better serve our members. We embrace and encourage differences in age, race, ethnicity, gender identity and expression, physical and mental ability, sexual orientation, socio-economic status and other characteristics that make people unique.
Today, guided by our mission of improving health and inspiring hope, we strive to be the leading provider of government-sponsored health insurance programsincluding Medicare, Medicaid, and PACEin the region.
Brief summary of purpose
The Transitions of Care Coordinator uses a multidisciplinary approach to ensure that SE participant transitions of care to and from inpatient facilities are appropriate, timely, and successful. In collaboration with the SE IDT ascertains that participants are in receipt of high quality cost efficient care and outcomes
Primary Job Responsibilities
Attends daily IDT meetings to discuss inpatients and suggest discharge plans
Utilize a checklist to ensure that the components of a safe transition of care occur
Communicates daily with primary team members to address potential barriers to discharge or transition to lesser care setting
Participates in family meetings as needed
Participates in contracted facility case management meetings to address potential barriers/facilitate successful discharge planning.
Collaborate with facilities, IDT members and others involved in participants plan of care to ensure safe, efficient transitions from facility to facility and to the home setting
Facilitate pertinent record exchange to and from facilities for continuity of care and medication reconciliation
Acts as a liaison between facilities and IDT members to convey progress
Access resources out of network to meet participant needs
Utilize Collective Medical to track transitions in real time
Supports the fundamental mission of the Summit ElderCare program
Determines tier of service at subacute facilities
Conduct concurrent and retrospective utilization review for inpatient, observation or SNF services
Recognizes, identifies, and implements appropriate opportunities to help meet Utilization goals
Knowledge of managed care, quality, and risk management principles
Participates in the SE Utilization Committee
Generate Ad Hoc request when required
Concurrent and retrospective review utilizing a multitude of systems and electronic records
Enters authorizations in applicable systems to ensure that claims are adjudicated efficiently
Documents all inpatient care transitions and case management progress notes within the electronic health record
Generate Transitions of Care Templates to accurately reflect transitions and level of care
Track Vendor Denials
Identify quality/risk factors in continuum of care and report to Medical Director and Quality Team
Utilize clinical judgement and critical thinking to suggest alternative measures for provision of care
Education
Associate of Science in Nursing, Bachelor of Science in Nursing (preferred)
License/Certifications
Licensed by the Commonwealth of Massachusetts Board of Registration in Nursing as a Registered Nurse. Valid Driver's License
CCM or similar certification desired
Experience
Three to five years nursing experience with one year experience working with a frail or elder population. Recent case management or utilization management experience and knowledge of criteria for medical necessity determination preferred. Must possess strong interpersonal, analytical and communication skills.
Fallon Health provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.
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