Senior Nurse Case Manager - Home Care Programs

Fallon Health•Worcester, MA

About The Position

Fallon Health is hiring a Senior Nurse Case Manager to serve as a clinical and operational lead for In Home Clinical Services (IHCS) and the Personal Care Attendant (PCA) Program. The role provides clinical triage, case consultation, program oversight, regulatory guidance, and interdisciplinary collaboration to resolve complex member issues while supporting compliance with state and organizational requirements. It serves as the primary point of ownership for escalated IHCS and PCA concerns, partnering with Nurse Case Managers, Navigators, LTSS teams, providers, vendors, and community partners to improve member outcomes, operational efficiency, and processes. The position represents Clinical Integration in IHCS meetings, reviews complex referrals and service concerns, facilitates interdisciplinary case consultations, coordinates follow-up, and monitors IHCS performance and barriers. For the PCA Program, it serves as the organizational subject matter expert on applicable MassHealth regulations, manages escalated cases, leads Time-for-Task reviews, supports decisions about eligibility and services, and consults on authorizations, appeals, denials, compliance, and EVV processes. The Senior Nurse Case Manager also provides expert support to clinical and operational staff, contributes to member-centered care planning, monitors program metrics, audits processes, develops improvement recommendations, supports policies and educational materials, participates in regulatory readiness activities, and leads special projects. The role requires an active, unrestricted Massachusetts RN license, at least three years of clinical RN experience, and reliable transportation for required in-person work. A valid driver’s license, compliance with the Driver Safety Policy, and proof of minimum state-required auto insurance are also required.

Requirements

Graduate of an accredited school of nursing.
Associate degree in nursing required.
Active, unrestricted Registered Nurse license in Massachusetts.
At least 3 years of clinical RN experience with complex medical, behavioral, and social comorbidities.
Ability to conduct assessments in person and via telehealth.
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 minimum state-required auto insurance.
Reliable transportation.
Reliable home internet.

Nice To Haves

Bachelor’s degree or higher in nursing.
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.

Responsibilities

Serve as the primary clinical liaison between Clinical Integration and IHCS, representing Clinical Integration in meetings, case conferences, and operational workgroups.
Review and triage complex IHCS referrals, service concerns, provider issues, and care coordination challenges.
Facilitate interdisciplinary consultations for members with complex clinical, behavioral, or social needs.
Coordinate communication and follow-up among IHCS providers, care teams, and leadership.
Identify barriers, trends, and systemic issues affecting IHCS members and recommend improvements to services and outcomes.
Monitor IHCS performance, service utilization, and operational effectiveness.
Serve as the organizational subject matter expert for the PCA Program and applicable MassHealth regulations.
Manage escalated PCA requests, concerns, service disputes, and operational challenges.
Lead Time-for-Task reviews and support clinical decision-making about PCA service needs.
Review complex PCA assessments and help staff interpret PCA eligibility guidelines.
Consult on PCA eligibility determinations, authorizations, appeals, denials, compliance requirements, and EVV processes.
Partner with LTSS, Utilization Management, Medical Directors, and EVV stakeholders on complex cases and service-delivery barriers.
Monitor PCA trends, including approvals, appeals, utilization, access barriers, and operational inefficiencies.
Lead efforts to standardize and improve PCA-related processes.
Provide expert consultation to Nurse Case Managers, Assessment Nurses, Navigators, Supervisors, and Leadership.
Support staff with complex member situations involving functional needs, LTSS, caregiver concerns, home-based support, and regulatory requirements.
Support member-centered care planning and service coordination; participate in case rounds, clinical reviews, quality initiatives, and operational meetings.
Escalate high-risk situations appropriately and ensure timely resolution.
Monitor program performance metrics, identify improvement opportunities, and conduct audits of IHCS and PCA processes.
Analyze trends and recommend operational enhancements; assist with policies, procedures, workflows, and educational materials.
Participate in readiness activities for regulatory audits and program evaluations.
Lead special projects and process improvement initiatives involving IHCS and PCA services.