RN Care Manager

• Provide monitoring, follow-up, and clinical care management to dually eligible enrollees with complex medical, behavioral, and social care needs
• Engage enrollees in their homes and community settings to establish complex care management relationships
• Consider members' cultural and linguistic needs
• Liaise between healthcare providers, community resources, and enrollees to support communication and care transitions
• Perform Comprehensive, MDS-HC or successor Functional, and Crisis and Risk Assessments
• Develop and implement care plans with enrollees and provide routine updates
• Lead interdisciplinary care teams and collaborate with internal and external peers
• Oversee utilization of long-term services and supports
• Assist members with housing, transportation, food assistance, and social services
• Educate members about Medicare, Medicaid, benefits, chronic condition management, medication adherence, and preventive care
• Promote healthy lifestyles and self-management strategies
• Support preventive health strategies and gap closure
• Follow up after hospitalizations or significant health events to support continuity and prevent readmissions
• Coordinate care with primary care physicians, specialists, healthcare providers, community organizations, state agencies, and service providers
• Advocate for enrollee needs and preferences
• Evaluate member satisfaction and monitor concerns
• Conduct regular member, provider, and community-based visits, with travel potentially exceeding 50% of work time
• Report abuse, neglect, or exploitation as a mandated reporter under state law
• Adhere to NCQA and Care Management standards
• Perform other job-related duties as requested

• Associate of Science (A.S.) degree in nursing from an accredited nursing program required
• Registered Nurse with ability to independently serve people with complex medical, behavioral, and social needs
• Current unrestricted clinical license in the Commonwealth of Massachusetts as a Registered Nurse (RN) required
• Intermediate proficiency with Microsoft Office, including Outlook, Word and Excel
• Understanding of Medicare and Medicaid programs and community resources for dual-eligible beneficiaries
• Strong interpersonal, communication, customer relations, and customer service skills
• Ability to manage multiple cases and priorities while maintaining attention to detail
• Ability to function independently and effectively as part of an interdisciplinary team
• Current valid driver's license, vehicle, and verifiable insurance
• Successful driver's license record check required
• Annual Influenza vaccination required during Influenza season
• Must reside in the assigned territory and within commutable distance to the Commonwealth of Massachusetts
• Prior experience in care coordination, case management, or working with dual-eligible populations preferred
• Medicaid and/or Medicare managed care experience preferred
• Clinical Field/Community Based Training a plus
• Case Management Certification highly preferred

Demonstrates expertise in care management for dually eligible enrollees, focusing on complex medical, behavioral, and social needs. Proficient in developing care plans, conducting assessments, and collaborating with interdisciplinary teams to ensure effective communication and continuity of care.

• Registered Nurse (RN)
• Care Coordination
• Medicare and Medicaid Knowledge
• Case Management Certification
• Interdisciplinary Team Collaboration

• Comprehensive Assessments
• Crisis and Risk Assessments
• Care Plan Development
• Utilization Management
• Medication Adherence Education

• Interpersonal Skills
• Communication Skills
• Customer Service Skills
• Attention to Detail
• Independent Functioning

• Registered Nurse License
• Case Management Certification
• Annual Influenza Vaccination

• Dually Eligible Populations
• Community Resources
• Health Care Transitions
• Preventive Health Strategies
• NCQA Standards

• Microsoft Office
• Outlook
• Word
• Excel