Hybrid Registered Nurse; RN Clinical Care Manager - South Holyoke

Job Summary

The Integrated Care Clinical Manager - Massachusetts at Care Source/Commonwealth Care Alliance (CCA) is a community based registered nurse responsible for providing monitoring, follow‑up and clinical care management to dually‑eligible enrollees with complex medical, behavioral and social care needs. The position focuses on integrating health services and community resources to coordinate enrollee care for improved health outcomes and enhanced quality of life.

• Engage with the enrollee in their homes and other community settings to establish an effective, complex care management relationship, considering the cultural and linguistic needs of each member.
• Function as a liaison between healthcare providers, community resources, and enrollees to ensure seamless communication and care transitions.
• Perform required assessments on a timely basis, including but not limited to Comprehensive Assessment, MDS‑HC (or successor) Functional Assessments, and Crisis and Risk Assessments.
• Engage enrollees in care plan development and implementation, providing routine updates as the enrollee's status changes.
• Lead the interdisciplinary care team (ICT) and collaborate with peers internally and externally to create holistic care plans addressing medical and non‑medical needs.
• Oversee enrollee utilisation of long‑term services and supports, ensuring appropriate systems are in place for enrollees to remain in the location of their choice.
• Assist members in accessing community resources, including housing, transportation, food assistance, and social services.
• Educate members about their benefits and available services under Medicare and Medicaid.
• Provide education to members and their families about managing chronic conditions, medication adherence, and preventive care.
• Promote healthy lifestyle choices and self‑management strategies.
• Assist enrollees in preventative health strategies, including gap closure.
• Follow up with members after hospitalizations or significant health events to ensure continuity of care and prevent readmissions.
• Work closely with primary care physicians, specialists, and other healthcare providers to coordinate care and share relevant information.
• Coordinate with community‑based organizations, other stakeholders, state agencies, and other service providers to prevent duplication of services and improve coordination.
• Advocate for the needs and preferences of enrollees within the healthcare system.
• Evaluate member satisfaction through open communication and monitoring of concerns or issues.
• Travel as required to conduct member, provider, and community‑based visits.
• Mandated reporter obligations for abuse, neglect, or exploitation of older adults and adults with disabilities must be adhered to as required by state law.
• Adhere to NCQA and Care Management standards.
• Perform any other job‑related duties as requested.

• Associate of Science (A.S.) degree in nursing from an accredited program.
• Must hold the RN license in the Commonwealth of Massachusetts and possess the ability to independently serve people with complex medical, behavioral, and social needs.
• Preferred:
  Prior experience in care coordination, case management, or with dual‑eligible populations.
• Preferred:
  Medicaid and/or Medicare managed care experience.
• Preferred:
  Clinical field or community‑based training.

• Intermediate proficiency with Microsoft Office (Outlook, Word, Excel).
• Understanding of Medicare and Medicaid programs and community resources available to dual‑eligible beneficiaries.
• Strong interpersonal, verbal, and written communication skills with ability to engage members, families, and providers.
• Capability to manage multiple cases and priorities while maintaining attention to detail.
• Commitment to professional ethical obligations.
• Sensitivity and awareness of diverse backgrounds and needs.
• Strong decision‑making and problem‑solving skills.
• Ability to function independently and as part of an interdisciplinary team.
• Customer‑service orientation and rapport‑building skills.

• Current unrestricted RN license in Massachusetts.
• Preferred:
  Certified…