Senior Care Options Care Navigator - Berkshire County

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:

Member Education, Advocacy, and Care Coordination

Conduct phone and, as appropriate, in-person assessments, screenings, and visits using TruCare; update individualized care plans and aim for first-contact resolution in a culturally responsive manner.
• Coordinate and follow up on care needs, including post-transition outreach, appointment scheduling, medication support, and service monitoring.
• Educate members/representatives on benefits, coverage criteria, rights, appeals, authorizations, and evidence of coverage.
• Identify and address gaps in care (e.g., PCP assignment, preventive screenings, vaccinations) per established protocols.
• Screen for social determinants of health and refer to community resources (e.g., food, housing, fuel assistance, transportation); escalate clinical decisions to the Nurse Case Manager or PCP.
• Advocate for members' access to covered benefits and coordinate with community agencies for non-covered supports.

Provider Partnerships and Collaboration

• Participate in-and as appropriate, lead-care plan meetings with providers, partners, and care team members.
• Collaborate with the interdisciplinary team (e.g., LTC, behavioral health, advanced practitioners, community partners) to support coordinated care.
• Build effective working relationships with community partners and providers (e.g., housing, ADH, assisted living, LTC facilities, PCPs) to support timely, member-specific communication.

Access to Care

• Submit and track requests/authorizations for covered services; ensure accuracy and timeliness per program workflows.
• Educate members and providers on authorization processes and help resolve authorization issues.
• Facilitate access to medical, behavioral health, and social services, including arranging transportation when needed.

Care Team Communication

• Communicate timely updates with members, caregivers, providers, and internal teams on care plans, service changes, and member status.
• Partner with LTC and community teams during admissions, transitions, and discharges to ensure continuity of care.

Regulatory Requirements, Documentation, and Reporting

• Complete required activities to meet CMS/State, NCQA, HEDIS, and other standards (e.g., welcome calls, screenings, care plans).
• Document accurately and on time in TruCare and related systems; review and validate member panel data and reports.

Additional Responsibilities

• Maintain knowledge of program benefits, policies, procedures, and community resources.
• Support operations by covering assignments, adapting to priorities, and completing other duties as assigned.
• Mentor or train staff on job-related processes and workflows, as assigned.

Education:

HS Diploma/GED required. College degree (BA/BS in Health Services or Social Work) preferred

License/Certifications: Certification: Community Health Worker - preferred

Other: Satisfactory Criminal Offender Record Information (CORI) results and access to reliable transportation

Experience:

• 2+ years' experience in managed care and/or community-based health and human services (e.g., home health, personal care management, independent living, ASAP, or relevant state agencies) preferred
• Understanding of hospitalization and post-discharge needs required
• Working knowledge of medical terminology, common conditions, and medical record documentation; able to identify triggers requiring RN intervention required
• Motivational interviewing experience and ability to work effectively with diverse and non-English-speaking populations required
• Understanding of social determinants of health required
• Proficiency with Microsoft Office (Excel, Outlook, Word) required
• Experience with face-to-face member visits and working with providers/community partners preferred

Pay Range Disclosure:

In accordance with the Massachusetts Wage Transparency Act, the pay range for this position is $28 - $30 per hour, which reflects what we reasonably and in good faith expect to pay at the time of posting. Final compensation will depend on the candidate's experience, skills, and fit with the role's responsibilities.

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.

#P01