Home-Based RN Care Manager (Integrated Care)

CareSource; Boston, Northern (MA, KY); Hybrid; USD 80,000 - 120,000; Full time

Job summary

CareSource's Integrated Care Clinical Manager in Massachusetts leads in-home and community-based care coordination for dually eligible enrollees with complex medical, behavioral, and social needs. You will guide the interdisciplinary team, coordinate with providers, and ensure seamless transitions to improve outcomes and quality of life.

Based in Massachusetts, this mobile role requires MA RN licensure, care management experience, and the ability to travel to member homes and community sites.

Qualifications

• Associates of Science (A.S) degree in nursing from an accredited nursing program required
• A Registered Nurse with the ability to independently serve people with complex medical, behavioral, and social needs. required
• Prior experience in care coordination, case management, or working with dual-eligible populations preferred
• Medicaid and/or Medicare managed care experience preferred
• Clinical Field/ Community Based Training a Plus

Responsibilities

• Engage enrollees in their homes and community settings to build a complex care management relationship.
• Coordinate care between providers and community resources for seamless transitions.
• Perform comprehensive assessments including MDS-HC and risk assessments.
• Lead the interdisciplinary care team to develop holistic care plans.
• Oversee enrollee utilization of long-term services and supports to support choice of living setting.
• Assist members in accessing housing, transportation, food assistance and social services.
• Educate members about benefits and services under Medicare and Medicaid.
• Provide education to members and families about managing chronic conditions and preventive care.
• Promote healthy lifestyle choices and self-management strategies.
• Follow up after hospitalizations to ensure continuity of care and prevent readmissions.
• Coordinate with community organizations and state agencies to avoid duplication of services.
• Advocate for the needs and preferences of enrollees within the healthcare system.
• Evaluate member satisfaction through open communication and monitoring of concerns.
• Regular travel to conduct member, provider and community visits as required.

Skills

Care coordination

Interdisciplinary teamwork

Home visits

Communication skills

RN licensure

Education

Associate of Science in Nursing

RN license (MA)

Tools

Microsoft Office

Job description

CareSource's Integrated Care Clinical Manager in Massachusetts leads in-home and community-based care coordination for dually eligible enrollees with complex medical, behavioral, and social needs. You will guide the interdisciplinary team, coordinate with providers, and ensure seamless transitions to improve outcomes and quality of life.

Based in Massachusetts, this mobile role requires MA RN licensure, care management experience, and the ability to travel to member homes and community sites.