Home-Based RN Case Manager: Complex Care & Coordination

Commonwealth Care Alliance Inc; Revere (MA); Hybrid; USD 80,000 - 120,000; Full time

Job summary

Commonwealth Care Alliance is seeking a Mobile Integrated Care Clinical Manager (RN) for Massachusetts to coordinate care for dually eligible enrollees with complex needs across home and community settings. You will lead a multidisciplinary team, perform comprehensive assessments, and ensure smooth transitions between providers and services.

The role focuses on integrating health services with community resources to improve outcomes, with travel across Massachusetts to support members in various

Qualifications

• RN license required.
• Experience in care coordination or case management preferred.
• Medicare/Medicaid knowledge preferred.
• Clinical field/community-based training a plus.

Responsibilities

• Engage with enrollees in their homes and community settings to build a complex care management relationship.
• Liaise between healthcare providers, resources, and enrollees to ensure seamless care transitions.
• Perform Comprehensive Assessments, MDS-HC/functional assessments, and risk assessments in a timely manner.
• Lead the interdisciplinary care team to develop holistic care plans.
• Coordinate long-term services to allow enrollees to remain in their preferred location.
• Assist members in accessing housing, transportation, food, and social services.
• Educate members on benefits, services, chronic condition management, medication adherence, and preventive care.
• Promote healthy lifestyles and self-management strategies.
• Follow up after hospitalizations to prevent readmissions.

Skills

RN license

Care coordination

Communication

Community health

Education

Associate of Science in Nursing

Tools

Microsoft Office

Job description

Commonwealth Care Alliance is seeking a Mobile Integrated Care Clinical Manager (RN) for Massachusetts to coordinate care for dually eligible enrollees with complex needs across home and community settings. You will lead a multidisciplinary team, perform comprehensive assessments, and ensure smooth transitions between providers and services.

The role focuses on integrating health services with community resources to improve outcomes, with travel across Massachusetts to support members in various