RN Case Manager: Holistic Care & Coordination

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

Job summary

Fallon Health is seeking a dedicated RN Case Manager to coordinate care for NaviCare members in Massachusetts. You will conduct in-person and telephonic assessments, reconcile medications, and craft care plans to meet member needs within benefit structures and community resources.

You will collaborate across interdisciplinary teams, educate members on benefits, and support self-management through coaching and health education. Experience with regulatory standards is essential.

Qualifications

• RN with Massachusetts license and nursing degree as required.
• Active, unrestricted RN license in Massachusetts.
• Certification in Case Management strongly desired, willingness to obtain when eligible.
• Driving a personal vehicle is an essential job function; valid license and auto insurance required.
• 1+ years of clinical RN experience with complex medical, behavioral, and social co-morbidities.
• Experience with in-person and telehealth assessments; interdisciplinary teams; social determinants of health.

Responsibilities

• Assess and manage a member panel through in-person and telephonic outreach.
• Complete medication reconciliations and care transition assessments.
• Educate members on benefits, rights, disease management, medications, and preventive screenings.
• Support member self-management through coaching and health education.
• Develop and update individualized care plans; coordinate services per program standards.
• Collaborate with Navigators, PCPs, Behavioral Health Case Managers, pharmacists, and community partners.
• Track progress toward goals and adjust care plans as needed.
• Participate in interdisciplinary rounds and team communication.
• Build relationships with members, caregivers, and providers for coordinated care.
• Complete assessments, screenings, notes, and care plans within regulatory timelines.

Skills

Communication

Interviewing

Care coordination

Problem-solving

Adaptability

Education

Associate’s degree in Nursing

Bachelor’s degree preferred

Job description

Fallon Health is seeking a dedicated RN Case Manager to coordinate care for NaviCare members in Massachusetts. You will conduct in-person and telephonic assessments, reconcile medications, and craft care plans to meet member needs within benefit structures and community resources.

You will collaborate across interdisciplinary teams, educate members on benefits, and support self-management through coaching and health education. Experience with regulatory standards is essential.