Brief summary of purpose:

The Assessment Nurse Case Manager completes face-to-face home visits for new enrollees within 30 days of enrollment to onboard and completes regulatory assessments. The Assessment Nurse Case Manager completes in person Health Risk Assessments (HRAs) in accordance with members assigned frequency. The Assessment Nurse Case Manager completes all new Personal Care Attendant (PCA) Assessments using the integrated time for task tool and well as yearly PCA reevaluations. The Assessment Nurse Case Manager is also responsible for the timely and accurate submission of yearly (and when there is a significant change in status) MDS assessments. Assessments are done primarily in person but may at times be completed telephonically. Responsibilities Overview Conducts home visits for onboarding and regulatory assessments.\nCompletes HRAs and PCA assessments.\nSubmits MDS assessments.\nProvides education on NaviCare case management program.\nConducts telephonic assessments when appropriate.\nCollaborates with Care Team.\nCompletes LTSS evaluations and collaborates with UM. Member Assessment, Education & Advocacy Conducts in-home assessments with motivational and culturally sensitive interviewing.\nPerforms medication reconciliation.\nCompletes State-required assessment tools per contract.\nConducts functional assessments for LTSS programs.\nParticipates in training and audits.\nCompletes telephonic/virtual assessments.\nMaintains program/policy knowledge to educate members.\nSupports HEDIS, Medicare 5 Star, and other initiatives.

Qualifications Education:

Graduate from an accredited school of nursing mandatory and a Bachelors (or advanced) degree in nursing or a health care related field preferred.

License:

Active, unrestricted license as a Registered Nurse in

Massachusetts Certification:

Certification in Case Management strongly desired

Other:

Driving your personal motor vehicle is an essential job function of this position and the following requirements apply: Must possess a valid drivers' license\nMust attest to no disqualifiers per Driver Safety Policy\nMust possess and provide proof of minimal state required auto insurance\nMust have reliable transportation

Experience:

1+ years of clinical RN experience with complex medical, behavioral, and social co-morbidities.\nAbility to conduct assessments in-person and telehealth.\nAbility to work on interdisciplinary teams.\nSkill in screening social determinants of health.\nStrong communication and interviewing skills.\nProblem-solving skills and adaptability.\nKnowledge or willingness to learn regulatory requirements.\nPreferred experience: Home Health, OASIS/MDS, Medicare/Medicaid, face-to-face member interactions.\nReliable home internet.

Pay Range Disclosure:

In accordance with the Massachusetts Wage Transparency Act, the pay range for this position is $95,000 - $100,000 per year, which reflects what we reasonably and in good faith expect to pay at the time of posting. Final compensation will depend on the candidate's experience, skills, and fit with the role's responsibilities. Fallon Health provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws. #

P01 NOT READY TO APPLY?

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