Hybrid Registered Nurse (RN) Care Manager

About the Role

The Integrated Care Clinical Manager - Massachusetts is a community-based registered nurse responsible for monitoring, follow-up, and clinical care management for dually-eligible enrollees with complex medical, behavioral, and social needs. This role focuses on integrating health services and community resources to coordinate enrollee care, improve health outcomes, and enhance quality of life. The position involves in-home and community visits and frequent collaboration with healthcare providers and community organizations.

What You'll Do

• Engage with enrollees in their homes and community settings to establish an effective complex care management relationship, considering cultural and linguistic needs.

• Function as a liaison between healthcare providers, community resources, and enrollees to ensure seamless communication and care transitions.

• Perform timely assessments including 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 both internal and external to create holistic care plans that address medical and non-medical needs.

• Oversee enrollee utilization 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 (housing, transportation, food assistance, and social services).

• Educate members about their benefits and available services under both 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/entities, state agencies, and other service providers to ensure coordination and avoid duplication of services.

• 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 regularly to conduct member, provider and community-based visits as required.

• Report abuse, neglect, or exploitation of older adults.

• What We're Looking For

• Current RN license to practice in Massachusetts; strong clinical foundation in care management and patient advocacy.

• Experience in community-based care management or care coordination for dually-eligible enrollees with complex needs.

• Ability to perform comprehensive assessments (e.g., Comprehensive Assessments, MDS-HC or successor) and Crisis/Risk Assessments.

• Excellent communication and interpersonal skills; proven ability to lead interdisciplinary care teams and coordinate with providers and community resources.

• Knowledge of Medicare and Medicaid benefits; experience educating members and families on managing chronic conditions, medications, and preventive care.

• Willingness to travel regularly for member, provider, and community-based visits.

• Commitment to culturally competent care and ability to tailor approach to diverse populations.

• Ability to advocate for member needs within the healthcare system and monitor satisfaction.

• Compensation & Benefits

• Hybrid role in Massachusetts with a $5,000 sign-on bonus.

• Travel required for member, provider, and community-based visits.