RN Case Manager: Community LTSS & Care Coordination

ForHealth Consulting at UMass Chan Medical School; Westborough (MA); Remote; USD 70,000 - 100,000; Full time

Job summary

ForHealth Consulting at UMass Chan Medical School is seeking a Nurse Reviewer II to oversee administrative case management within the Community Case Management Program in Massachusetts. This role collaborates with a multidisciplinary team to assess, plan, and coordinate long-term services for Members and ensure care continuity.

The ideal candidate is an RN licensed in MA with 5–7 years of direct or case management experience in pediatric, young adult, or medically complex populations, and the

Qualifications

• RN licensed to practice in Massachusetts
• 5-7 years of work experience with direct service or case management to pediatric/young adult/medically complex populations
• Ability to travel statewide to Member homes and service providers
• Experience with Office Applications and databases

Responsibilities

• Serve as the clinical manager for an assigned caseload of Members.
• Contribute to assess, plan, organize, review and evaluate care needs of Members requiring health care services.
• Conduct on-site reviews and assessments to determine medical necessity and eligibility for Community Case Management and Continuous Skilled Nursing Services.
• Prepare and implement Member service records.
• Coordinate, facilitate and monitor the delivery of services to Members.
• Review and document information into data system applications per guidelines and regulations.
• Conduct routine and ad-hoc evaluations of Members' services.
• Engage providers and state agencies to obtain information for clinical reviews and determinations.
• Evaluate and document appropriateness of Members' services and modify as needed.
• Maintain individual records and write clinical summaries.
• Promote continuity of care by liaising with providers and hospitals.
• Respond to inquiries related to appeals on clinical determinations.
• Maintain relationships with peers, leadership, Members, providers, and state agencies.
• Maintain confidentiality per HIPAA and procedures.
• Participate in performance improvement initiatives and training of new staff.
• Comply with departmental policies and objectives.
• Perform other duties as required

Skills

Case management

Clinical assessment

Education

RN licensure in Massachusetts

Tools

Office applications

Database access

Job description

ForHealth Consulting at UMass Chan Medical School is seeking a Nurse Reviewer II to oversee administrative case management within the Community Case Management Program in Massachusetts. This role collaborates with a multidisciplinary team to assess, plan, and coordinate long-term services for Members and ensure care continuity.

The ideal candidate is an RN licensed in MA with 5–7 years of direct or case management experience in pediatric, young adult, or medically complex populations, and the