Job Description
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, Fallon Health delivers equitable, high-quality, coordinated care and is continually rated among the nation's top health plans for member experience, service, and clinical quality.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 (Program of All-Inclusive Care for the Elderly)-- in the region.Learn more at fallonhealth.org or follow us on Facebook, Twitter and LinkedIn.Brief summary of purpose:The Navigator is an integral part on an interdisciplinary team focused on care coordination, care management and improving access to and quality of care for Fallon members.The Navigator is an integral part of the Fallon Health interdisciplinary team and communicates members needs to providers and other community supports, while ensuring all members of the care team are informed of member issues and concerns.The Navigator seeks to establish telephonic relationships with the member/caregiver(s) and provider partners to better ensure ongoing service provision and care coordination, consistent with the member needs.To effectively advocate for member needs, the Navigator must be a subject matter expert in benefit structure and coverage of both Community Care and Medicare product lines.The Navigator must also have working knowledge of all products offered by Fallon Health to refer members as appropriate as well as a basic understanding of Mass Health guidelines.Further, the Navigators are subject matter experts on all social care needs, assisting members in obtaining the care and support that they need to get needed care and to remain in the community safely.The Navigator must be familiar with quality metrics including STARS and HEDIS as well as guiding factors within the NCQA standards as well as CAHPS survey questions to best align members' care to meet these metrics.Responsibilities:Primary Job Responsibilites Note:Job Responsibilities may vary depending upon the member's Fallon Health Insurance Product Member Education, Advocacy, and Care Coordination Telephonically manages incoming/outgoing calls with the goal of first call resolution with each interaction Conducts telephonic (face to face if required) member visits to assess member needs utilizing TruCare Assessment Tools Establish and develop effective working relationships with community partners such as Elder Services, community organizations, 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 Educate members/PRAs about their product specific benefits and how to access often times facilitating and coordinating such Educates members/PRAs on referrals and prior authorizations- assists members in obtaining these as needed Provides education to providers on prior authorizations and referrals Responds promptly to member calls/questions and follows up per department processes at all times demonstrating exceptional customer service skills in a culturally sensitive way Provides culturally appropriate care coordination i.e.:arranges for interpreters, provides communication documents in appropriate language, demonstrates culturally appropriate behavior when working with member/family Develops and fosters relationships with members and providers/facilities and depending upon the product, to be the first point of contact for benefit related questions and is able to explain processes including but not limited to:coverage criteria, appeal rights and processes, authorization request process, formulary, and evidence of coverage details Assists the interdisciplinary team in identifying and addressing member barriers related to social determinants of health and care obtainment Collaborate with the interdisciplinary team in identifying and addressing high risk members and transitions of care Serves as an advocate for members to ensure they receive Fallon Health benefits as appropriate and if member needs are identified but not covered by Fallon Health, works with community agencies to facilitate access to programs such as community transportation, food programs, and other services available through community senior/cultural centers and other external partners