Triage Case Manager - Hybrid

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 or purpose: The Case Manager Triage Nurse for IHCS and PCA Program Management serves as the primary clinical subject matter expert and operational lead for In Home Clinical Services (IHCS) and the Personal Care Attendant (PCA) Program. This role provides clinical triage, case consultation, program oversight, regulatory guidance, and interdisciplinary collaboration to ensure timely resolution of complex member issues while supporting compliance with state and organizational requirements. The Triage Nurse functions as the single point of ownership for escalated IHCS and PCA concerns, partnering with Nurse Case Managers, Navigators, LTSS teams, providers, vendors, and community partners to optimize member outcomes, support operational efficiency, identify trends, and drive continuous process improvement. This role is designed as a hybrid of a Nurse Case Manager, clinical triage specialist, program manager, and operational subject matter expert. The goal is to create single-point ownership for complex IHCS and PCA issues while allowing frontline staff to focus on direct member management. Responsibilities Primary Job Responsibilities: IHCS Clinical Management & Triage 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 members receiving IHCS. Develop recommendations to improve service delivery, communication, and member outcomes. Monitor IHCS…