Hybrid RN Case Manager: IHCS & PCA Program Lead

Fallon Health; Worcester (MA); On-site; USD 95,000 - 100,000; Full time

Job summary

Fallon Health is seeking a skilled RN to lead the IHCS triage and PCA program management in Massachusetts. You will provide clinical triage, coordinate care, and ensure regulatory compliance while collaborating with LTSS and medical directors.

The role blends nursing leadership with program oversight, emphasizing quality care, process improvement, and member outcomes. A Massachusetts RN license and home internet are required.

Qualifications

• -3+ years of clinical RN experience.
• -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 interactions.
• -Reliable home internet.

Responsibilities

• Serve as the primary clinical liaison between Clinical Integration and IHCS.
• Represent Clinical Integration in IHCS meetings, case conferences, and operational workgroups.
• Review and triage complex IHCS referrals and care coordination challenges.
• Coordinate communication between IHCS providers, care teams, and leadership.
• Identify service barriers, trends, and systemic issues affecting IHCS.
• Develop recommendations to improve service delivery and member outcomes.
• Monitor IHCS performance, service utilization, and operational effectiveness.
• Lead PCA program eligibility reviews and EVV-related processes.
• Collaborate with LTSS, Utilization Management, and Medical Directors on complex PCA cases.
• Monitor PCA approvals, appeals, and utilization; identify barriers.
• Lead efforts to standardize PCA-related processes.
• Provide expert clinical consultation to Nurse Case Managers and leadership.
• Assist staff with resolving complex member situations and regulatory requirements.
• Participate in case rounds, quality initiatives, and operational meetings.

Skills

RN experience

Interdisciplinary teamwork

Assessments

Social determinants of health

Communication skills

Problem-solving

Regulatory knowledge

Home health

Education

RN degree (Associate's or Bachelor's)

Job description

Fallon Health is seeking a skilled RN to lead the IHCS triage and PCA program management in Massachusetts. You will provide clinical triage, coordinate care, and ensure regulatory compliance while collaborating with LTSS and medical directors.

The role blends nursing leadership with program oversight, emphasizing quality care, process improvement, and member outcomes. A Massachusetts RN license and home internet are required.