OverviewAbout 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 Social Work Care Manager (SWCM) works very closely with Fallon Health Care Team staff, Provider Partners, Community Partners,and/ or community-based groups to address service gaps and serves as a liaison to social and health resources on behalf of Fallon Healthand the Fallon Health Care Management Models of Care.The SWCM collaborates and coordinates with State Agencies, DMH, DDS, DYS, DCF to ensure members care is efficient and coordinated.The SWCM provides social service coordination services to members as referred assessing member needs, services and resources toaddress social, health, or economic needs and facilitates referrals and collaboration with Provider Care Teams and BH Partners in thecommunity.The SWCM assists the member and or family to provide care utilizing FH benefits and/or community resources developing a plan tocoordinate a continuum of care consistent with the members’ health care needs and/or goals. The SWCM uses their knowledge of benefitplan design, eligibility and/or financing alternatives available within the community to provide options that meet member’s needs.The SWCM identifies services, care delivery settings, and funding arrangements that meet the needs of the members. They recommendsalternatives where appropriate. The SWCM monitors services and provides consistent feedback to the team on progress.The SWCM collaborates and works with members of the Care Team both at Fallon Health and at the Community Partners during time ofmember transition of care.May attend in person care planning meetings, care coordination meetings, partner communication meetings, and other face-to-facemeetings with providers, partners, and members to perform assessments, train staff, coordination communication and otherwise representFallon Health in a positive way.SWCM seeks to establish telephonic and/or face to face relationships with the member/caregiver(s) to better ensure ongoing serviceprovision and care coordination, consistent with the member specific care plan developed by the BHCM and Care Team.Responsibilities may include conducting in home/office face to face visits for member identified as needing face to face visit interaction andassessments with the goal to coordinate and facilitate services to meet member needs according to benefit structures and availablecommunity resources. The SWCM conducts assessments and refers members to community resources. The SWCM may utilize an ACDline to support department and incoming/outgoing calls with the goal of first call resolution with each interaction.ResponsibilitiesPrimary Job Responsibilities:Member Care Coordination and Collaborationo Provides culturally appropriate care coordination, i.e., works with interpreters, provides communication approved documentsin the appropriate language, and demonstrates culturally appropriate behavior when working with member, family, caregivers,and/or authorized representativeso With member/authorized representative(s) collaboration develops member centered care plans by identifying member careneeds while completing program assessments and working with the Care Coordinator to ensure the member approves theircare plano Monitors progression of member goals and care plan goals, provides feedback and works collaboratively with care teammembers and work effectively in a team model approach to coordinate a continuum of care consistent with the Member’shealth care goals and needso Actively participates in internal clinical rounds and huddleso Works with members of the Utilization Management Department assisting with difficult or complex care delivery or dischargeplanning needs for memberso Actively participate with Beacon team and collaborate on high-risk members to decrease utilizationo May collaborate with staff on site to facilitate communication between Fallon and community-based teamso Assists with care coordination with community Partners to engage in Interdisciplinary team meetingso Works with Nurse Case Managers and Navigators to coordinate a continuum of care for members consistent with themember’s health care goals and needso Maintains an ongoing awareness of clinical, social, and financial resources available in the community as well asState/Federal and National Resources and connects and advocates for members as appropriateo Performs other responsibilities as assigned by a member of the Clinical Integration Leadership TeamProvider Partnerships and Collaborationo May attend in person member/provider visits, care plan meetings with providers and office staff and may lead care planreview with providers and care team as applicableo Demonstrates positive customer service actions and takes responsibility to ensure member and provider requests and needsare metRegulatory Requirements – Actions and Oversighto Completes Program Assessments, Notes, Screenings, and Care Plans in the TruCare and Provider EMR systems accordingto Program policies and processesProvides training and consultationo Offers recommendations to continued program development and is an active participant in suggesting opportunities to enhancethe programo Works with Fallon Health Provider Relations and Beacon Health Options to ensure that contracted behavioral health providersare knowledgable about the plan benefits, eligibility requirements, and care coordination and communication needso Coordinate with Beacon staff to ensure quality and timely arrangement of necessary mental health and substance use supports.Attends Fallon Health/Beacon meetings when requestedo Attends supervision and 1:1 meetings with Leader. Attends Team Huddles, staff meetings, site meetings and other Fallon Healthand business related meetings as required. Meetings may be in person or telephonic depending upon the needOthero Performs other responsibilities as assigned by the Manager/designeeo Supports department colleagues, covering and assuming changes in assignment as assigned by Manager/designeeQualificationsEducation:Master’s degree from an accredited school of social work, mental health counseling, psychology, or human services requiredLicense/Certifications:License: Active, unrestricted license as a Licensed Clinical Social Worker or Counselor in Massachusetts; reliable transportationCertification: Certification in Case Management a plusOther: Satisfactory Criminal Offender Record Information (CORI) resultsExperience:Four years of experience working with the following: the chronically ill, SPMI, and substance use populations requiredExperience and comfort conducting face-to-face visits with members in the community and in home settings requiredExperience working in a multi-disciplinary care team requiredExperience working and providing collaborative care management interventions with various State Agencies such as DMH, DDS, DCF, DYS requiredExperience working with provider groups such as medical and/or mental health providers requiredBackground working with all age groups preferredPrevious experience working at a Managed Care Organization preferredCOVID-19 Vaccination:With the end of the Global Coronavirus COVID-19 Pandemic, Fallon Health no longer requires all employees to be vaccinated against COVID-19 except for employees who are in jobs that under state and federal laws, regulations and policies are required to be vaccinated and/or they are in Member/participant facing positions.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-WorcesterPosted Date 7 hours ago (1/7/2025 12:29 PM)Job ID 7805# Positions 1Category Social Work
