Home Health RN Case Manager - Newburyport Area

Tufts Medicine • Newburyport, MA

6d • Onsite

About The Position

The Home Health Registered Nurse manages and delivers comprehensive home health services to clients in their residences, including assessments, interventions, and supportive care, using the nursing process and in accordance with physician orders. Depending on circumstances, the role may also include telephone triage, problem solving, patient and caregiver advocacy, and support, with an emphasis on avoiding hospitalization.

As a member of the healthcare team, the nurse works courteously and effectively with patients and families, agency colleagues, community resources, and physicians to facilitate safe and efficient care. The position independently manages an assigned caseload within a team-based care model, maintains patient records and required documentation, and helps coordinate care and discharge planning. The role includes rotating evening, night, weekend, and holiday coverage and requires working in patients’ homes and the surrounding community.

Requirements

• Active RN license in the state where services are provided; the nurse may not work in states where they are not licensed. Any additional required state license must be obtained within 60 days.
• Valid state-issued driver’s license.
• At least one year of acute medical/surgical nursing experience.
• Basic Life Support (BLS) certification.
• For hires before 9/28/2026, CPR certification is required upon hire. For hires after 9/28/2026, BLS certification is required within 30 days of hire.
• Demonstrated knowledge and skills to provide appropriate care to the ages of patients served.
• Knowledge and skills in home health and hospice standards of care, symptom management, and psychosocial and spiritual aspects of care.
• Ability to communicate, read, and write in English, with excellent interpersonal skills.
• Ability to manage time, prioritize a busy schedule, and function effectively and independently in a home care setting.
• Good organizational skills.
• Ability to exchange accurate information by phone, email, or in person and to communicate frequently with internal and external parties.
• Ability to perform the physical demands of the role, including standing, walking, sitting, hand use, reaching, stair climbing, balancing, stooping, kneeling, crouching, crawling, and lifting or moving up to 25 pounds regularly and up to 100 pounds occasionally.

Nice To Haves

• Bachelor of Science in Nursing (BSN).
• Specialty nursing certifications.
• Three years of acute nursing experience, including medical/surgical, oncology, hospice, or home health.
• Experience with IV therapy and complex wound care.

Responsibilities

• Assess patients’ physical and psychosocial needs and provide ongoing interdisciplinary assessment in accordance with nursing standards and agency policies.
• Assess patient and family learning needs, styles, and limitations, and adapt information delivery accordingly.
• Recognize and respect patient and caregiver cultural beliefs about death and dying.
• Set realistic goals and develop treatment plans with patients, families, and the healthcare team.
• Identify suspected abuse or neglect and follow agency reporting procedures.
• Adapt to new or unusual situations and use security resources when needed for potentially unsafe situations.
• Collaborate with patients, families, healthcare providers, and community resources on care and discharge planning.
• Evaluate patient and family progress and goal achievement, keep the Clinical Manager informed, and justify continuation or termination of services.
• Document patient data, activities, and communications in the patient record accurately and promptly using the computer system.
• Complete physicians’ orders, levels of care, and OASIS documentation for assigned patients; reconcile medications with patients and physicians.
• Follow safety procedures, including ergonomics, fire safety, personal safety, proper body mechanics, and patient and material handling.
• Respond appropriately to emergencies and follow established safety, security, and stabilization protocols.
• Provide supportive care and respond appropriately to patient and family emotional stress.
• Manage the assigned caseload, set a daily work plan according to patient and area priorities, and triage visits, messages, and calls by urgency.
• Provide nursing coverage on a rotating basis for evenings, nights, weekends, and holidays.
• Use strong physical assessment and care-planning skills and maintain current knowledge of pharmacology, medication administration, and medication reconciliation.
• Coordinate care and discharge planning with team members during case conferences.
• Maintain working knowledge of third-party payers, regulatory requirements, agency policies, documentation, and care standards.
• Communicate and collaborate regularly with home care disciplines and promptly address critical needs or crises.

Benefits

• Competitive salaries and benefits.
• Medical, dental, and vision benefits starting on day one.
• 403(b) retirement plan with company match.
• Tuition reimbursement and continuing education support, including MedBridge access for PT continuing education and licensure or certification support.
• Career growth opportunities.
• Fleet car program.
• Workplace safety and violence prevention program, including AVADE de-escalation and self-safety training, InvisaWear GPS-enabled safety devices, and escort services for field staff.

What This Job Offers

• Job Type: Full-time
• Career Level: Senior
• Education Level: No Education Listed