Triage Nurse Case Manager — IHCS & PCA Lead

Fallon Community Health Plan, Inc.; Worcester (MA); Hybrid; USD 95,000 - 100,000; Full time

Job summary

Fallon Health in Worcester, MA is seeking a Case Manager Triage Nurse for IHCS and the PCA Program Management. The role blends nursing triage, case management, and program oversight to resolve complex member issues while ensuring regulatory compliance.

Collaboration with LTSS teams, providers, and leaders drives improved outcomes. The position supports hybrid operations with a focus on care coordination, quality improvement, and readiness for regulatory audits.

Qualifications

• RN licensure in Massachusetts (active, unrestricted).
• Graduate from an accredited school of nursing; ADN required, BSN preferred.
• 3+ years of clinical RN experience with complex medical, behavioral, and social co-morbidities.

Responsibilities

• Serve as the primary clinical liaison between Clinical Integration and IHCS; participate in meetings and case conferences.
• Review and triage complex IHCS referrals, service concerns, and care coordination challenges.
• Facilitate interdisciplinary case consultations for members with complex needs.
• Coordinate communication between IHCS providers, care teams, and leadership; monitor performance and trends.
• Lead PCA program oversight, eligibility interpretation, and regulatory compliance discussions.
• Support staff in PCA service decisions, authorizations, and EVV-related processes.
• Provide expert consultation to Nurse Case Managers, Assessment Nurses, Navigators, and leadership.

Skills

RN experience

Case management

Interdisciplinary teamwork

Clinical triage

Education

Nursing degree (ADN required, BSN preferred)

Job description

Fallon Health in Worcester, MA is seeking a Case Manager Triage Nurse for IHCS and the PCA Program Management. The role blends nursing triage, case management, and program oversight to resolve complex member issues while ensuring regulatory compliance.

Collaboration with LTSS teams, providers, and leaders drives improved outcomes. The position supports hybrid operations with a focus on care coordination, quality improvement, and readiness for regulatory audits.