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Fallon Health Clinical Integration Nursing, Manager in Worcester, Massachusetts


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 accredited by the National Committee for Quality Assurance for its HMO, Medicare Advantage and Medicaid products. For more information, visit

About NaviCare :

Fallon Health is a leader in providing senior care solutions such as NaviCare, a Medicare Advantage Special Needs Plan and Senior Care Options program. Navicare integrates care for adults age 65 and older who are dually eligible for both Medicare and MassHealth Standard. Apersonalized primary care team manages and coordinates the NaviCare member’s health care by working with each member, the member’s family and health care providers to ensure the best possible outcomes.

Brief Summary of Purpose:

The Manager, Clinical Integration Nursing is responsible for:

  • Managing a multi-location clinical team to ensure timely coordination of quality healthcare and care coordination services for Fallon Health members with varying levels of conditions

  • Actively participating in developing case management system platform structure (CaseNET TruCare System) in conjunction with division leaders, Fallon Health I.T. and recommends modifications for workflow efficiencies and reporting enhancements

  • Providing leadership, supervision, and support for nursing and disease management/health educator staff fostering integration within care teams and member care plans

  • Collaboratively works with Clinical Integration Leaders to implement Models of Care, Programs as outlined in Program Descriptions for various Fallon Health products ensuring adherence to CMS, State, NCQA, and other required elements

  • Ensuring the Fallon Health members have an effective and compliant care plan to meet the member care needs according to product requirements working with clinical integration staff and leaders to ensure compliance and effectiveness of care plan

  • Ensuring team performance goals are met and ensuring program staff are trained and compliant with departmental and policy requirements

  • Auditing team member documentation and working with staff to implement corrective action as warranted

  • Developing training modules working in conjunction with Clinical Integration Trainers

  • Educating Clinical Integration Team members on various levels of care coordination/case management interventions and recommending andsupporting team actions to ensure effective member care plan development and implementation – active participant in Clinical Integration Rounds

  • Developing and implementing quality improvement projects and strategies to support the Program in meeting quality and performance measures including, but not limited to, NCQA, HEDIS, CMS, State, Medicare Five Star, External Quality Review projects, etc.

  • Preparing and presenting member cases files for auditors, regulators, and others as required

  • Providing management of designated provider and or vendor relationships as assigned, including but not limited to supporting embedded and enhanced provider partnership relationships

  • Partnering and leading relationships with State Agencies such as Aging Service Access Points, Adult Day Health Care, Group Adult Foster Care, Adult Foster Care, Long Term Care Providers, LTSS Providers, Provider groups, and other vendors and providers fostering collaborative working relationships


Team Management:

  • Hires, orients, supervises, evaluates, counsels and terminates staff that function within the assigned Team

  • Provides education to the Team on the Model of Care, policies, procedures, workflows, and best practices to manage member care

  • Oversees performance of Team ensuring Program and Team goals are met utilizing reports and facilitating team independent use of such

  • Establishes Team member productivity and professional goals in conjunction with the Program Leadership Team

  • Evaluates staff performance based on these defined goals and implements coaching and performance improvement measures and actions when necessary

  • Recommends, develops, and works with TruCare I.T. Development team to ensure case management documentation system effective to meet Program needs

  • Develops workflows and educates Team on workflows as appropriate

  • Monitors Team adherence to established workflows and implements improvements and workflow modifications as required

  • Meets 1:1 with Direct Reports at least monthly and more frequently based upon need and utilizes established reports and systems to track and ensure performance to Team member and Program goals

  • Audits Team member documentation for accuracy, timeliness, appropriateness, and adherence to workflow and implements corrective action when warranted

  • Performs and/or ensures Team performs quality and inter-rater reliability audits on a regular basis to assure compliance with the Program’s policies and procedures

  • Ensures staff utilize an effective communication style and methods to engage members/personal representatives in care manageme

Program Leadership Activities – Quality Improvement Focus (as assigned):

  • Leads, participates in, and implements quality improvement projects

  • Ensures team members follow workflow and reporting requirements to support projects and outcome requirements of programs including but not limited to Transition of Care and Emergency Room utilization

  • Responsible for development and implementation of care transition protocols for Program membership

  • Documents and presents Quality Improvement Projects to regulatory agencies including but not limited to Center for Medicare and Medicaid Services (CMS), External Quality Review Organizations (EQRO), and other accrediting and regulatory oversight agents

  • Develops, generates, and or utilizes reports produced by the Data Specialist and Program Support Team to ensure Team performance to goal

  • Utilizes reporting software to generate process measure reports for team performance oversight and teaches team members to be proficient utilizing reporting software to produce their own reports

  • Recommends modifications to the Model of Care and participates in activities associated with cost of care projects, and other initiatives associated with Program financial improvement

Member Related Oversight (as assigned):

  • Facilitates and/or conducts Team huddles up to three times per week – Team huddle content includes but is not limited to members experiencing a care transition and proactive brainstorming and planning to modify member care plans – involves clinical resources as appropriate

  • Ensures department team members work collaboratively with members of the Fallon Health Utilization Management Department

  • In conjunction with Medical Director/Vice President/designee, facilitates the Team with discharge planning for Program member situations as applicable

  • In conjunction with Medical Director/Vice President/Director/designee, ensures the Fallon Health members have an effective care plan to meet the member’s needs

  • In conjunction with Medical Director/Vice President/Director/designee, ensures staff modify member care plans based upon member need working to creatively and effectively implement plans that have positive outcomes for the member and the Plan

Program Oversight (as assigned):

  • Updates policies and processes and ensure processes meet regulatory/contract and efficiency requirements

  • Trains staff on policies/processes and Resource Library use

  • Develops and updates new hire training program and ensures staff are trained and proficient throughout their employment tenure

  • Works with Medical Director/Vice President/Director/designee to identify best practices for management of members and works with Medical Director/Vice President/Director/designee to identify and then implement workflow and process changes

  • Evaluates staffing and operational needs to ensure that the day-to-day operations of the Team are carried out in compliance with departmental and health plan budgetary requirements and works with Director/designee and peers to readjust staffing for teams based upon census need

Provider/Vendor Relationship (as assigned):

  • Collaborates with vendors/providers such as the Aging Service Access Point Staff and Long Term Care Facility Staff to ensure the Member care needs are met

  • Leads vendor relationship(s) with contracted providers to ensure an effective and positive relationship between organizations

  • Supports Program efforts to embed team members in provider locations and works to ensure team members communicate effectively with provider partners

  • Participates as the “Clinical Team Subject Matter Expert” in Provider Orientations and/or Refreshers in collaboration with Provider Relations and Outreach teams


  • Works collaboratively and cohesively with all members of the care team (both internal and external staff and providers)

  • Maintains an ongoing awareness of clinical, social, and financial resources available in the community

  • Supports department colleagues, covering and assuming changes in assignment as assigned by Director/designee

  • Strictly observes HIPAA regulations and the Fallon Health policies regarding confidentiality of member information

  • Performs other responsibilities as assigned by the Director/designee



Graduate from an accredited school of nursing or social/behavioral health mandatory. Bachelors (or advanced) degree in a health care related field preferred

License :

Active, unrestricted license as a Registered Nurse in Massachusetts; OR Licensed Mental Health Clinician; OR Licensed Mental Health Family Therapist; OR Licensed Independent Clinical Social Worker; AND current Driver’s license

Certification :

Certification in Case Management strongly desired


Satisfactory Criminal Offender Record Information (CORI) results


  • A minimum of three years clinical experience as a licensed clinician managing/coordinating/facilitating/providing care for elders over the age of 65 required and experience working with other age population ages too required

  • Two years of supervisory or management experience in a health care setting; preferably with experience supervising/managing a mix of clinical and non-clinical staff required

  • Experience working in a healthcare setting as a member of a professional team coordinating care for adult populations who are diagnosed with health conditions or chronic disease, including mental illness of substance use disorders required

  • Familiarity with in home services both skilled and non-skilled, outpatient services including medical and behavioral health, knowledge of different levels of care including but not limited to acute, rehab, long term, and experience with Medicare and Medicaid coverage criteria and requirements required

  • Three years’ experience performing care coordination in a managed care setting required

  • Experience developing policies, procedures, and workflows required

  • Experience with performance improvement projects including but not limited to establishing criteria for report queries, utilizing objective data to improve processes, and implementation of projects required

  • Experience with improvement methodologies including but not limited to lean and six sigma a plus

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.

Location US-MA-Worcester

Posted Date 4 days ago (1/13/2021 12:50 PM)

Job ID 6126

# Positions 1

Category Nursing