Care Manager (MA / Field-based)

FreedomCare•North Shore, MA

4d•Onsite

About The Position

FreedomCare is seeking a field-based Care Manager for its Massachusetts team. The role supports the MassHealth Adult Foster Care (AFC) program, which helps eligible adults with medical, physical, cognitive, or behavioral health needs receive daily assistance at home from a qualified caregiver, supported by a professional care team. The Care Manager conducts initial home assessments to determine eligibility for Home Health functional scale services and completes required monthly and quarterly in-home visits to assess care quality, patient and caregiver well-being, safety, and compliance. The position also provides caregiver education and coaching, supports consumers with service questions and barriers within a non-clinical scope unless licensed, and coordinates concerns and follow-up with the Care Team, Clinical, physicians, and leadership. Frequent travel to patients’ homes in the North Shore, Massachusetts area is required.

Requirements

Bachelor’s degree and a Massachusetts social worker license, plus at least two years of recent experience working with elders or adults with disabilities; or a bachelor’s degree and two years of clinical experience caring for elders or people with disabilities.
Negative tuberculosis screening result.
Valid driver’s license and insurance, with reliable transportation.
Demonstrated commitment to high-quality customer service and ability to communicate with empathy, patience, professionalism, and respect.
Strong active listening skills to understand patient needs, clarify concerns, and provide support or escalation as appropriate.
Effective verbal and written communication skills, including summarizing interactions, documenting case activity, and communicating case status and next steps.
Strong coaching and listening skills and ability to build trust and discuss sensitive barriers.
Strong typing and computer proficiency, including ability to navigate contact center technology, customer relationship management systems, and other software while accurately documenting interactions.
Effective problem-solving and critical thinking, sound judgment, and ability to identify solutions and escalate concerns when necessary.
Dependability, punctuality, consistent attendance, schedule adherence, and ability to meet performance expectations.
Ability to adapt to changing priorities, processes, systems, and business needs in a fast-paced environment.
Receptiveness to coaching and feedback and ability to apply guidance and demonstrate continuous improvement.
Ability to collaborate as part of a team while working independently within established guidelines.

Nice To Haves

At least two years of health coaching, care coordination, patient support, or community health experience.

Responsibilities

Conduct initial and ongoing in-home assessments of caregiver quality of care and skill proficiency, patient care needs, and the safety and suitability of the care setting.
Complete required monthly and quarterly in-home visits to monitor care quality and patient and caregiver well-being.
Coach and educate caregivers through in-person demonstrations and self-guided training in the learning management system.
Support consumers with service questions, goals, barriers, resources, and next steps while remaining within non-clinical scope unless licensed.
Document coaching interactions, outcomes, risks, referrals, and follow-up tasks in required systems.
Develop, implement, evaluate, and revise clients’ plans of care, including the physician’s plan of treatment and problem list.
Identify barriers related to care continuity, engagement, adherence, social needs, or customer experience.
Meet required call, outreach, quality, documentation, and follow-up standards.
Coordinate care through written documentation and communication with the Care Team, Clinical, physicians, and leadership for escalation or handoff.
Use empathetic, motivational, and culturally responsive communication with customers.
Escalate safety, clinical, compliance, or urgent customer concerns according to process.