RN Case Manager - SCO program - Hybrid - Fall River

Fallon Health • Fall River, MA

3d • Hybrid

About The Position

The RN Nurse Case Manager (NCM) is an integral member of an interdisciplinary team focused on care coordination, care management, and improving access to and quality of care for NaviCare members. The NCM builds face-to-face and telephonic relationships with members and caregivers to support ongoing services and coordinated care consistent with each member’s care plan.

The role includes in-person visits for members who need face-to-face interaction and care planning, with the goal of coordinating services that meet member needs within benefit structures and available community resources. The NCM completes transition-of-care assessments in person or by telephone, reconciles medications at transitions, creates and updates care plans, and carries out care-planning activities for medically complex members. The NCM collaborates with Navigators and other care partners to address medical concerns and provide holistic case management.

This hybrid position is based in Fall River. Driving a personal motor vehicle is an essential job function.

Requirements

• Graduate from an accredited school of nursing; an associate’s degree is required.
• Active, unrestricted Registered Nurse license in Massachusetts.
• At least 1 year of clinical RN experience with complex medical, behavioral, and social co-morbidities.
• 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.
• Valid driver’s license.
• Must attest to having no disqualifiers under the Driver Safety Policy.
• Must possess and provide proof of the minimum state-required auto insurance.
• Must have reliable transportation.

Nice To Haves

• Bachelor’s degree or higher.
• Certification in Case Management; willingness to obtain certification when eligible.
• Home Health experience.
• OASIS/MDS experience.
• Medicare/Medicaid experience.
• Experience with face-to-face member interactions.
• Reliable home internet.

Responsibilities

• Assess and manage a member panel through in-person and telephonic outreach.
• Complete medication reconciliations and care transition assessments.
• Educate members on benefits, rights, disease management, medications, and preventive screenings.
• Ensure members and authorized representatives participate in and approve care plans.
• Support member self-management through coaching and health education.
• Develop and update individualized care plans based on assessments.
• Coordinate services and authorize care according to program and regulatory standards.
• Collaborate with Navigators, primary care providers, Behavioral Health Case Managers, pharmacists, and community partners.
• Track progress toward member goals and adjust care plans as needed.
• Participate in interdisciplinary rounds and team communication.
• Build relationships with members, caregivers, and providers to support coordinated, culturally appropriate care.
• Complete assessments, screenings, notes, and care plans within regulatory timelines.
• Follow HIPAA and organizational confidentiality policies.
• Support HEDIS, Medicare 5-Star, and quality initiatives through outreach and education.
• Assist with departmental campaigns, projects, and coverage as assigned.

What This Job Offers

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