Nurse Case Manager - Assessment for SCO program - Fall River/New Bedfored

Fallon Health•New Bedford, MA

About The Position

The Assessment Nurse Case Manager completes face-to-face home visits for new enrollees within 30 days of enrollment to onboard members and complete regulatory assessments. The role performs in-person Health Risk Assessments (HRAs) at the frequency assigned to each member, completes new Personal Care Attendant (PCA) assessments using the integrated time-for-task tool, and conducts yearly PCA reevaluations. The position is also responsible for timely and accurate submission of annual Minimum Data Set (MDS) assessments and assessments when a member experiences a significant change in status. Assessments are primarily conducted in person, but may sometimes be completed by telephone or virtually. The Nurse Case Manager provides education about the NaviCare case management program, completes LTSS evaluations, collaborates with Care Team members and Utilization Management (UM), and supports initiatives including HEDIS and Medicare 5 Star. The position requires in-person and telehealth assessment work, including home visits using the employee’s personal motor vehicle.

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 social determinants of health.
Strong communication and interviewing skills.
Problem-solving skills and adaptability.
Knowledge of, or willingness to learn, regulatory requirements.
Must possess a valid driver’s license.
Must attest to having no disqualifiers under the Driver Safety Policy.
Must possess and provide proof of at least the state-required auto insurance.
Must have reliable transportation.

Nice To Haves

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

Responsibilities

Conduct home visits for member onboarding and regulatory assessments.
Complete Health Risk Assessments (HRAs) at members’ assigned frequency.
Complete new Personal Care Attendant (PCA) assessments using the integrated time-for-task tool and perform yearly PCA reevaluations.
Submit yearly MDS assessments and assessments prompted by significant changes in member status accurately and on time.
Provide education about the NaviCare case management program and maintain program and policy knowledge to educate members.
Conduct telephonic or virtual assessments when appropriate.
Collaborate with the Care Team and with Utilization Management on LTSS evaluations.
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.
Support HEDIS, Medicare 5 Star, and other initiatives.