Manager, Clinical Integration Navigators

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 manager, clinical integration navigators leads a centralized navigator support function responsible for operational excellence across care coordination and service delivery. This role overseas team performance,develops standardized workflows, and establishes effective intake, triage, and escalation processes particularly for DME, Dental, and PCA services. The manager partners closely with internal stakeholders, providers, vendors, and IT to ensure regulatory compliance, operational efficiency, and consistent high-quality support from members, providers, and care teams.

Primary Job Responsibilities (include duties that represent 5% or more of employee's time)

Operations Program Ownership

Accountable for the end-to-end design, implementation and optimization of program workflows supporting care coordination services
• Leads the translation of organizational and department direction into scalable standardized operational models, ensuring navigator support programs are consistently executed across teams and services
• Ensures operational readiness prior to the rollout of new or revised support workflows, tools, or vendor relationships, including validation of processes, staff preparedness, documentation, standards and escalation pathways, develops documents and maintains policies, procedures, and standardized workflows to promote consistency regulatory compliance and sustainable performance
• Designs and overseas intake, triage, and resolution processes for complex and high volume service requests, including durable medical equipment (DME), dental and personal care attendant (PCA) services
• Partners with IT, operations, and internal stakeholders to optimize system functionality, workflow efficiency, and reporting capabilities that support navigator support programs
• Ensures effective integration and collaboration across navicare care management teams by defining clear roles, workflows, and operational handoffs

Providor and Vendor Management

• Oversee collaborative relationships with provider groups, including embedded and enhanced partnerships
• Represent Navicare program with external partners for care management program
• Resolves systemic operational issues affecting providers, vendors or navigator workflows
• Establish and maintain vendor escalation pathways, communication standards, and service expectations
• Monitor vendor performance and collaborate on workflow improvements for enhanced service delivery

Quality, Compliance, and Operational Support

• Navigator support operations align with regulatory and contractual requirements
• Support audits, reviews, and performance improvement initiatives related to workflows
• Ensure consistent documentation practices in quality across the team

Leadership

• Oversee the Support Navigator Supervisor and daily support team operations
• Establish performance expectations, monitor productivity, quality, and service outcomes of support team
• Provide coaching, performance management and support professional development
• Ensure staff training compliance and adherence to workflows and documentation standards
• Collaborate with care management, quality, utilization management, provider relations, and operational teams
• Serve as subject matter expert for navigator support operations and escalation frameworks
• Perform other duties as assigned consistent with the role

Required Experience

• Three+ years of supervisory/management experience in a healthcare setting, experience leading both clinical and non-clinical staff
• Coordinating care as part of an interdisciplinary team for adult populations with chronic conditions, including behavioral health conditions and or substance use disorder
• Knowledge of home services (skilled/non-skilled), medical and behavioral health services, and levels of care (acute, rehab, long-term)
• Working knowledge of Medicare and Medicaid coverage criteria and requirements experience developing policies, procedures, and operational workflows
• Experience leading performance improvement initiatives using objective data (e.g. defining report/query criteria, implementing process changes)
• Lean Six Sigma or similar continuous improvement methodology

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.