RN Case Manager

Fallon Health•Worcester, MA

About The Position

The RN Nurse Case Manager 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 role 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 RN Case Manager conducts in-person visits for members who need face-to-face interaction and care planning, coordinating services according to benefit structures and available community resources. The role completes transition-of-care assessments, reconciles medications at transitions, creates initial care plans, updates plans as needed, and carries out care-planning activities for medically complex members. The RN collaborates with Navigators and other care partners to address medical concerns and provide holistic case management.

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 regulatory requirements or willingness to learn them.
Valid driver’s license.
Must attest to having no disqualifiers under the Driver Safety Policy.
Must possess and provide proof of at least 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.
Experience in Home Health, OASIS/MDS, Medicare/Medicaid, or 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 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.