RN Case Manager

Responsibilities

• Manage a diverse caseload, ensuring quality patient care and efficient care coordination.
• Provide coaching, oversight, and support to Home Health Aides (HHAs) to ensure high-quality patient care and adherence to clinical standards.
• Develop and implement individualized care plans based on patient assessments and goals.
• Coordinate with PCPs, therapy providers, and internal support teams to ensure comprehensive care.
• Provide education and support to patients and families regarding their health care needs and treatment plans.
• Maintain accurate and timely electronic charting, with a preference for real‑time documentation.
• Ensure all documentation meets regulatory and Abby Care standards, with a minimum of 24‑hour turnaround time.
• Establish and maintain effective communication with PCPs, therapy providers, and internal support teams.
• Escalate appropriate issues to Clinical Leads in a timely manner, such as order management and patient concerns.
• Participate in on‑call rotation (approximately one weekend per month), holiday rotation, and possible phone triage night coverage during weekdays.
• Achieve caregiver satisfaction by providing high-quality, compassionate care and support.
• Monitor and work to improve patient readmission rates.
• Ensure extended visits remain within acceptable ranges and administrative tasks (e.g., mileage reimbursements) are completed thoroughly.

• An Associate's Degree or a Baccalaureate School of Nursing Degree.
• Current and valid license as a Registered Nurse in the state of Massachusetts.
• 2 years of experience as a Registered Nurse in a clinical setting; 1 year of home health experience preferred.
• Case management/supervisor experience and pediatric/adult care experience preferred.
• Knowledge of Medicaid paid family caregiving program and HHA scope of practice preferred (training provided if needed).
• Reliable transportation, valid driver's license, and current auto insurance required.
• Ability to work flexible hours, travel locally, and provide on‑call service to patients/families.
• Knowledge of OASIS preferred (training provided if needed).

Demonstrates expertise in patient care management, including the development and implementation of individualized care plans, effective communication with healthcare teams, and adherence to clinical standards. Proficient in electronic charting and documentation, ensuring compliance with regulatory requirements and organizational standards.

• Patient Assessment
• Care Plan Development
• Electronic Charting
• Care Coordination
• Clinical Standards Adherence

• Effective Communication
• Coaching and Oversight
• Compassionate Care
• Problem-Solving

• Registered Nurse License in Massachusetts