Assessment Nurse Case Manager

Fallon Health • Worcester, MA

4d

About The Position

The Assessment Nurse Case Manager conducts home visits for new enrollees within 30 days of enrollment to support onboarding and complete regulatory assessments. The role performs in-person Health Risk Assessments (HRAs) at the frequency assigned to members, completes new Personal Care Attendant (PCA) assessments using the integrated time-for-task tool, and conducts annual PCA reevaluations. The nurse is also responsible for timely, accurate submission of annual Minimum Data Set (MDS) assessments and assessments required when a member experiences a significant change in status. Assessments are primarily in person but may sometimes be completed by phone or virtually.

The position provides education about the NaviCare case management program, conducts Long-Term Services and Supports (LTSS) evaluations, and collaborates with the care team and Utilization Management (UM). It includes member advocacy, medication reconciliation, culturally sensitive interviewing, and support for HEDIS, Medicare 5 Star, and other initiatives. Driving a personal motor vehicle is an essential job function.

Requirements

• Graduate from an accredited school of nursing.
• Active, unrestricted Registered Nurse license in Massachusetts.
• At least 1 year of clinical RN experience with complex medical, behavioral, and social comorbidities.
• Ability to conduct in-person and telehealth assessments.
• Ability to work on interdisciplinary teams.
• Skill in screening for social determinants of health.
• Strong communication and interviewing skills.
• Problem-solving skills and adaptability.
• Knowledge of, or willingness to learn, regulatory requirements.
• Valid driver’s license.
• Must attest to having no disqualifiers under the Driver Safety Policy.
• Must possess and provide proof of at least the minimum state-required auto insurance.
• Must have reliable transportation.

Nice To Haves

• Bachelor’s degree or advanced degree in nursing or a health care-related field.
• Certification in Case Management is strongly desired.
• Experience in Home Health, OASIS/MDS, Medicare/Medicaid, or face-to-face member interactions.
• Reliable home internet.

Responsibilities

• Conduct home visits for onboarding and regulatory assessments.
• Complete Health Risk Assessments (HRAs) according to members’ assigned frequency.
• Complete new Personal Care Attendant (PCA) assessments using the integrated time-for-task tool and conduct yearly PCA reevaluations.
• Submit yearly MDS assessments and assessments required when there is a significant change in member status, accurately and on time.
• Provide education about the NaviCare case management program.
• Conduct telephonic or virtual assessments when appropriate.
• Collaborate with the care team and Utilization Management (UM).
• Conduct in-home assessments using motivational and culturally sensitive interviewing.
• Perform medication reconciliation.
• Complete State-required assessment tools in accordance with contract requirements.
• Conduct functional assessments for LTSS programs.
• Participate in training and audits.
• Maintain knowledge of programs and policies to educate members.
• Support HEDIS, Medicare 5 Star, and other initiatives.
• Drive a personal motor vehicle as an essential function of the position.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Associate degree