RN Case Manager

RN Nurse Case ManagerThe RN Nurse Case Manager (NCM) is an integral part of an interdisciplinary team focused on care coordination, care management and improving access to and quality of care for NaviCare members. The NCM seeks to establish face-to-face and telephonic relationships with the member/caregiver(s) to better ensure ongoing service provision and care coordination, consistent with the member specific care plan developed by the NCM and Care Team. Responsibilities may include conducting in-house face-to-face visits for members identified as needing face-to-face visit interaction and care planning with the goal of coordinating and facilitating services to meet member needs according to benefit structures and available community resources. NCMs are responsible for completing all Transition of Care Assessments, which may be done both in person and telephonically. The NCM is responsible for reconciling all medications at time of transition. The NCM creates all initial care plans, updates care plans as needed and executes care planning activities for medically complex members. The NCM collaborates with Navigators on the care of all members to address medical concerns and to provide holistic and comprehensive case management.ResponsibilitiesMember Assessment, Education, and AdvocacyAssess 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.Care Coordination and CollaborationDevelop and update individualized care plans based on assessments.Coordinate services and authorize care according to program and regulatory standards.Collaborate with Navigators, PCPs, 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 strong relationships with members, caregivers, and providers for coordinated, culturally appropriate care.Regulatory Requirements – Actions and OversightComplete 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.QualificationsEducationRNs: Graduate from an accredited school of nursing, associate's degree required, bachelor's or higher preferredLicense/CertificationsLicense: RN Candidates (Required) Active, unrestricted license as a Registered Nurse in MassachusettsCertification: Certification in Case Management strongly desired, willingness to obtain when eligibleOther: Driving your personal motor vehicle is an essential job function for this position and the following requirements apply:Must possess a valid drivers' licenseMust attest to no disqualifiers per Driver Safety PolicyMust possess and provide proof of minimal state required auto insuranceMust have reliable transportationExperience1+ years of clinical RN experience with complex medical, behavioral, and social co-morbidities.Ability to conduct assessments in-person and 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 or willingness to learn regulatory requirements.Preferred experience: Home Health, OASIS/MDS, Medicare/Medicaid, face-to-face member interactions.Reliable home internet.Pay Range Disclosure:In accordance with the Massachusetts Wage Transparency Act, the pay range for this position is around $95,000 - $100,000 per year, which reflects what we reasonably and in good faith expect to pay at the time of posting. Final compensation will depend on the candidate's experience, skills, and fit with the role's responsibilities.Fallon Health provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.