Home Health RN, Case Manager

Job Profile Summary

This role focuses on providing professional and nonprofessional nursing care services in accordance with physician orders. The position requires the assessment, planning, implementation, and evaluation of the care needs of a designated group of patients or the provision of nursing care and identified clinical support tasks within the scope of practice for achievement of the patient’s plan of care as directed.

It is a professional individual contributor role that may direct the work of lower level professionals or manage processes and programs. The majority of time is spent overseeing the design, implementation, or delivery of processes, programs and policies using specialized knowledge and skills typically acquired through advanced education. A senior level role that requires advanced knowledge of the job area typically obtained through advanced education and work experience, managing projects/processes, working independently with limited supervision, coaching and reviewing the work of lower level professionals, and resolving difficult and sometimes complex problems.

Utilizing the nursing process, the Home Health Registered Nurse will manage and deliver comprehensive home health services, including assessments, interventions, and supportive care to clients within their place of residence. Duties may also include telephone triage, problem solving, patient/caregiver advocacy, and support with emphasis on avoiding hospitalization. As a key member of the health care team, this position must interact courteously and effectively with patients, families, coworkers from all Agency departments, community resources, and physicians to facilitate safe and efficient patient care while maintaining safety in the home and community.

Massachusetts – Merrimac, Amesbury, Salisbury, Newburyport and surrounding areas.

Full‑Time, Days, 40 Hours, 8am-4:30pm. Weekend/Holiday Commitment.

• Assess patients’ physical and psychosocial needs in a sensitive, caring manner following established Standards of Nursing Practice and VNA procedures.
• Assess patient/family learning needs, style, and limitations and adjust delivery of information.
• Establish realistic goals and develop plans of treatment in cooperation with the patient, family, and health care team.
• Adapt to new and unusual situations without negatively affecting performance.
• Utilize security when needed for any potential unsafe situations.
• Collaborate with patient/family and other health care providers and community resources for planning of care and discharge.
• Complete physicians’ orders, levels of care, and OASIS on all patients assigned in accordance with patient care policies.
• Reconcile medications with patient and physician consistently.
• Cope with patient/family emotional stress and provide appropriate supportive care.
• Effectively manage assigned caseload within the team model of care delivery.
• Establish a daily work plan based on patient/family priorities of service and total area needs.
• Promptly triage patient visits, messages, and phone calls according to priority and urgency.
• Demonstrate excellent physical assessment and care planning skills.
• Maintain current knowledge of pharmacology and medication administration and reconciliation.
• Coordinate care and discharge planning with other team members during case conferences.
• Maintain expert knowledge of third‑party payers, regulatory bodies, and agency policies related to documentation and care.
• Communicate and collaborate with all disciplines in the home care setting on a regular basis or immediately when critical needs or crisis interventions arise.

• Competitive salaries & benefits
• Medical, Dental, and Vision benefits start day one
• 403(b) retirement with company match
• Tuition reimbursement
• Opportunities for career growth

$84,300.22 – $

Tufts Medicine is an equal opportunity employer.