Overview

About us:

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 Elderly–PACE 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 programs—including Medicare, Medicaid, and PACE— in the region. 

Responsibilities

Clinical eligibility assessment

• Participates in establishing monthly goals for enrollment.
• Responds to individual inquiries regarding Summit ElderCare, including but not limited to, phone calls, web site inquiries, home visits, hospital and nursing home visits. 
• Reviews the enrollment process with potential members/families/referrers.
• Determines individual’s monthly premium and eligibility for Medicaid assistance.
• Completes the MDS, estimates whether individual meets clinical criteria for enrollment, and enters MDS into the Virtual Gateway. Manages questions from EOEA.
• Communicates with the Interdisciplinary Team to provide information for enrollment decisions and provides ongoing communication with referral sources, potential enrollees/families during the intake process.
• Coordinates and communicates necessary information about potential enrollees to the Summit Site Director on an ongoing basis.
• Provides referrals to other programs for individuals not appropriate for SE and for those who choose not to enroll.
• Facilitates weekly enrollment meetings.
• Keeps informed of NaviCare eligibility requirements and makes referrals as appropriate.
• Assist with completion of MDS assessments annually at assigned SE site.

Data management and reporting

• Assures uniformity in data collection.
• Prepares weekly reports regarding referrals and enrollments.
• Maintains referral tracking system and contact file.
• Participates in planning home visit requests. Attends home visits and completes documentation in the electronic medical record and attends intake meetings at their respective site followed by documentation in the electronic medical record. Prioritizes home visits according to forecast. Updates the home visit database. Initiates the opening of the EMR and enters clinical and demographic information.
• Conducts clinical presentations as required.

Monitors compliance

• Keeps informed of general Medicaid eligibility guidelines and supplemental insurance issues as they affect SE enrollment as well as the Medicare CMS regulation for PACE

Qualifications

Education: Degree in Nursing, BSN preferred

Licenses/Certifications: RN, current license to practice in Massachusetts and Valid Driver’s License and Clean Driving Record Required

Experience:

• 2 years’ experience working with the elderly, preferably in a community setting
• Knowledge of sales, customer service, outreach and marketing principles and practices preferred
• Knowledge of Medicaid eligibility requirements desirable
• Case management experience desirable

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.

Fallon Health Vaccination Requirements:

To protect the health and safety of our workforce, members and communities we serve, Fallon Health now requires all employees to disclose COVID-19 vaccination status. As of 2/1/2022 all roles not designated as “Remote” require full COVID-19 vaccination and Fallon Health will obtain the necessary information from candidates prior to employment to ensure compliance. Failure to meet the vaccination requirement may result in rescission of an employment offer or termination of employment.