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Triage Case Manager
Fallon Health. Serve as the primary clinical liaison between Clinical Integration and IHCS .
Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in clinical liaison roles, case management, and service coordination, with a strong focus on improving member outcomes and operational effectiveness. Proficient in navigating regulatory requirements and conducting assessments in diverse settings.
Highest-signal resume keywords
Registered Nurse License in MassachusettsCertification in Case Management3+ Years of Clinical RN ExperienceInterdisciplinary Team CollaborationKnowledge of Medicare/Medicaid Regulations
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Clinical AssessmentCare CoordinationService Utilization MonitoringPCA Eligibility DeterminationOperational Effectiveness Analysis
Soft Skills
Strong Communication SkillsProblem-Solving SkillsAdaptabilityInterviewing Skills
Tools & Technologies
Telehealth PlatformsEVV ProcessesOASIS/MDS
Certifications & Qualifications
Registered Nurse LicenseCertification in Case Management
Industry Keywords
Home HealthMassHealth RegulationsSocial Determinants of HealthInterdisciplinary Case ConsultationsQuality Initiatives
About the role
Key responsibilities & impact- Serve as the primary clinical liaison between Clinical Integration and IHCS
- Represent Clinical Integration in IHCS meetings, case conferences, and operational workgroups
- Review and triage complex IHCS referrals, service concerns, provider issues, and care coordination challenges
- Facilitate interdisciplinary case consultations for members with complex clinical, behavioral, or social needs
- Coordinate communication and follow-up between IHCS providers, care teams, and leadership
- Identify service barriers, trends, and systemic issues impacting IHCS members
- Develop recommendations to improve service delivery, communication, and member outcomes
- Monitor IHCS performance, service utilization, and operational effectiveness
- Serve as the organizational subject matter expert for the PCA Program and applicable MassHealth regulations
- Manage escalated PCA requests, concerns, service disputes, and operational challenges
- Lead Time-for-Task reviews and support clinical decision-making regarding PCA service needs
- Review complex PCA assessments and assist staff with PCA eligibility guidelines
- Consult on PCA eligibility determinations, service authorizations, appeals, denials, compliance requirements, and EVV processes
- Partner with LTSS, Utilization Management, and Medical Directors on complex PCA cases
- Collaborate with EVV stakeholders to identify barriers and develop solutions
- Monitor PCA approvals, appeals, service utilization, access barriers, and operational inefficiencies
- Lead consistency and standardization improvements for PCA-related processes
- Provide expert consultation to Nurse Case Managers, Assessment Nurses, Navigators, Supervisors, and Leadership
- Support member-centered care planning and service coordination
- Participate in case rounds, clinical reviews, quality initiatives, and operational meetings
- Escalate high-risk situations and ensure timely resolution
- Monitor program performance metrics and identify improvement opportunities
- Conduct IHCS and PCA process audits for compliance and consistency
- Analyze trends and recommend operational enhancements
- Assist with policies, procedures, workflows, and educational materials
- Participate in regulatory audit and program evaluation readiness activities
- Lead IHCS and PCA special projects and process improvement initiatives
Requirements
What you’ll need- Graduate from an accredited school of nursing
- Associate’s degree required; bachelor’s degree or higher preferred
- Active, unrestricted license as a Registered Nurse in Massachusetts
- Certification in Case Management strongly desired; willingness to obtain when eligible
- 3+ years of clinical RN experience with complex medical, behavioral, and social co-morbidities
- Ability to conduct assessments in-person and telehealth
- Ability to work on interdisciplinary teams
- Skill in screening social determinants of health
- Strong communication and interviewing skills
- Problem-solving skills and adaptability
- Knowledge or willingness to learn regulatory requirements
- Preferred experience in Home Health, OASIS/MDS, Medicare/Medicaid, and face-to-face member interactions
- Reliable home internet
- Valid driver’s license
- No disqualifiers per Driver Safety Policy
- Proof of minimal state-required auto insurance
- Reliable transportation
Benefits
Comp & perks- Equal employment opportunities and protection from discrimination and harassment
- Hybrid work arrangement
- Certification in Case Management strongly desired, with willingness to obtain when eligible