In-Home RN Case Manager & Care Coordinator

Fallon Community Health Plan, Inc.; Worcester, Northern (MA, KY); Hybrid; USD 95,000 - 100,000; Full time

Job summary

Fallon Health in Massachusetts seeks an Assessment Nurse Case Manager to perform face-to-face home visits for onboarding, complete Health Risk Assessments (HRAs) and PCA assessments, and ensure timely MDS submissions. Assessments are primarily in person, with telephonic options as needed.

The role requires MA RN licensure, a nursing degree, and at least 1 year of clinical RN experience with complex conditions; certification in case management is a plus.

Qualifications

• Must have RN license in Massachusetts.
• 1+ year of clinical RN experience with complex medical, behavioral, and social co-morbidities.
• Ability to conduct in-person and telehealth assessments.
• Experience with home health, MDS/OASIS, and Medicare/Medicaid a plus.

Responsibilities

• Conducts in-home visits for onboarding and regulatory assessments.
• Completes HRAs and PCA assessments.
• Submits MDS assessments.
• Provides education on NaviCare case management program.
• Conducts telephonic assessments when appropriate.
• Collaborates with the care team and UM.
• Performs LTSS evaluations as needed.

Skills

Motivational interviewing

Interdisciplinary teamwork

Communication

Problem solving

Education

Graduate from an accredited nursing school

Bachelor's degree in nursing or healthcare field

Job description

Fallon Health in Massachusetts seeks an Assessment Nurse Case Manager to perform face-to-face home visits for onboarding, complete Health Risk Assessments (HRAs) and PCA assessments, and ensure timely MDS submissions. Assessments are primarily in person, with telephonic options as needed.

The role requires MA RN licensure, a nursing degree, and at least 1 year of clinical RN experience with complex conditions; certification in case management is a plus.