Care Manager, RN (Peabody, MA Market /Field Based)

FreedomCare•Peabody, MA

1d•Remote

About The Position

FreedomCare is seeking a dedicated Care Manager, RN to join our Massachusetts team. This is a field-based position requiring regular travel throughout an assigned Massachusetts territory to conduct in-home visits and support member care. The role involves supporting the MassHealth Adult Foster Care (AFC) program, which assists eligible adults with daily needs in a home setting, supported by a caregiver and professional care team. The Care Manager, RN is responsible for initial in-home assessments, orientations for new patients and caregivers, and ongoing care management. This position combines clinical assessment, care coordination, patient and caregiver education, and quality assurance to ensure safe, effective, and person-centered care. The RN will collaborate with patients, caregivers, and care teams to assess needs, develop care plans, and facilitate service delivery. Key duties include conducting clinical assessments, developing and monitoring care plans, monitoring health status, providing clinical oversight and education to caregivers, and coordinating care with various providers. Proactive communication of clinical concerns and changes in condition is essential for timely intervention and optimal patient outcomes.

Requirements

Current, unrestricted license as a registered nurse issued by the Massachusetts Board of Registration in Nursing.
At least two years of recent experience providing direct care to elders or adults with disabilities, preferred.
Completion of tuberculosis screening before assignment and ongoing screening consistent with applicable CDC, Massachusetts Department of Public Health, and MassHealth requirements.
Successful completion of required CORI, SORI, OIG exclusion, reference, employment-history, and professional-license checks.
Must not be related to or legally responsible for a member assigned to the RN.
Valid driver’s license, required automobile insurance, reliable transportation, and ability to travel to member qualified settings.
Strong clinical judgment, critical-thinking, and problem-solving skills.
Knowledge of person-centered care, professional nursing standards, and home- and community-based services.
Knowledge of the health, functional, cognitive, behavioral, and safety needs of elders and adults with disabilities.
Ability to learn, interpret, and consistently apply Massachusetts Adult Foster Care regulations, MassHealth requirements, clinical protocols, and organizational policies.
Demonstrated commitment to high-quality member and caregiver service.
Ability to communicate with empathy, patience, professionalism, cultural sensitivity, and respect.
Strong active-listening and interviewing skills, with the ability to identify needs, risks, barriers, and concerns.
Effective verbal and written communication skills, including the ability to explain clinical information clearly to members, caregivers, and interdisciplinary partners.
Strong clinical documentation skills, with attention to accuracy, completeness, clarity, and timeliness.
Strong organizational, prioritization, time-management, and caseload-management skills.
Ability to recognize urgent clinical, health, safety, or compliance concerns and exercise sound judgment regarding escalation.
Ability to provide clear, effective, and culturally responsive education to members and caregivers.
Ability to establish and maintain professional, supportive relationships with members, caregivers, primary care providers, and community partners.
Ability to collaborate effectively with nurses, care managers, program leadership, and other members of a multidisciplinary professional team.
Ability to work independently in home- and community-based settings while remaining accountable to established clinical and operational standards.
Proficiency with electronic documentation systems, secure communication tools, and other healthcare technology required for the role.
Ability to protect member privacy, confidentiality, dignity, rights, and informed choice.
Dependable, punctual, and able to consistently meet scheduling, attendance, documentation, and performance expectations.
Ability to adapt to changing member needs, clinical priorities, regulatory requirements, processes, and technology.

Nice To Haves

At least two years of recent experience providing direct care to elders or adults with disabilities.

Responsibilities

Conduct initial in-person clinical assessments and coordinate timely service activation, ensuring all required documentation, approvals, and standard procedures are completed.
Develop, implement, and manage individualized plans of care, making and documenting revisions as the patient’s needs or condition change.
Educate patients, caregivers, and internal teams regarding care needs, safety considerations, service requirements, caregiver responsibilities, and next steps.
Coordinate patient care through timely communication and documentation with physicians, clinical disciplines, internal partners, and appropriate community resources.
Provide ongoing education and coaching to support effective use of established best practices, promote caregiver competency, and connect patients and families with appropriate resources.
Review caregiver documentation regularly and respond appropriately to identified changes in the patient’s condition, environment, or service needs.
Identify changes in condition, safety concerns, service gaps, incidents, or other urgent issues and escalate them in accordance with established clinical protocols.
Complete and document assessments, visits, clinical observations, care-plan updates, incidents, communications, and follow-up actions accurately, thoroughly, and within required timeframes.
Support authorization, renewal, start-of-care, and continued-service processes, as applicable.
Maintain compliance with all applicable regulatory requirements, professional standards, and company policies and procedures.
Perform other related duties as assigned by the supervisor.