MA - Worcester County North/Fitchburg - RN Case Manager

Abby Care•Worcester, MA

2d•$90,000 - $105,000•Onsite

About The Position

Abby Care is seeking a passionate Registered Nurse to join their team as an RN Case Manager. This role will report to the Director of Nursing in Massachusetts and is a Full-Time opportunity based in the Worcester County North/Fitchburg Area. The RN Case Manager at Abby Care provides comprehensive care and coordination of services for patients within their caseload. This role requires a nurse with excellent organizational skills, strong communication abilities, and a dedication to providing high-quality patient care. The RN Case Manager will work closely with patients, families, Primary Care Physicians (PCPs), therapy providers, and internal support teams to ensure optimal patient outcomes.

Requirements

An Associate's Degree or A Baccalaureate School of Nursing Degree.
Current and valid license as a Registered Nurse in the state of Massachusetts.
2 years of experience as a Registered Nurse in a clinical setting; 1 year of home health experience preferred.
Reliable transportation, valid driver's license, and current auto insurance required.
Ability to work flexible hours, travel locally, and provide on-call service to patients/families.

Nice To Haves

Bilingual in spanish
Case management/supervisor experience and pediatric/adult care experience preferred.
Knowledge of Medicaid paid family caregiving program and HHA scope of practice preferred (training provided if needed).
Knowledge of OASIS preferred (training provided if needed).

Responsibilities

Manage a diverse caseload, ensuring quality patient care and efficient care coordination.
Provide coaching, oversight, and support to Home Health Aides (HHAs) to ensure high-quality patient care and adherence to clinical standards.
Develop and implement individualized care plans based on patient assessments and goals.
Coordinate with PCPs, therapy providers, and internal support teams to ensure comprehensive care.
Provide education and support to patients and families regarding their health care needs and treatment plans.
Maintain accurate and timely electronic charting, with a preference for real-time documentation.
Ensure all documentation meets regulatory and Abby Care standards, with a minimum of 24-hour turnaround time.
Establish and maintain effective communication with PCPs, therapy providers, and internal support teams.
Escalate appropriate issues to Clinical Leads in a timely manner, such as order management and patient concerns.
Participate in on-call rotation (approximately one weekend per month), holiday rotation, and possible phone triage night coverage during weekdays.
Achieve caregiver satisfaction by providing high-quality, compassionate care and support.
Monitor and work to improve patient readmission rates.
Ensure extended visits remain within acceptable ranges and administrative tasks (e.g., mileage reimbursements) are completed thoroughly.