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RN Case Manager

Company: Impresiv Health
Location: Boston
Posted on: May 16, 2022

Job Description:

Role Description :
Under the administrative direction of the Clinical Manager, the Nurse Case Manager (NCM) for Senior Care Options (SCO) is responsible to manage all aspects of member care for a panel of frail elderly, while working within a healthcare team. The NCM directly interfaces with physicians, other members of the primary care team, members, and their caregivers in identifying risk factors, conducting assessments, and developing and implementing care plans to comprehensively manage their members' care. Member assessments will be conducted in person within the member's home.

Accountabilities :
The NCM will have a clear understanding of the role and will demonstrate a commitment to executing on the following responsibilities:


  • Timely completion of initial and ongoing geriatric assessments
  • Development and communication (with member, caregiver and primary care physician/primary care team) of an individualized plan of care
  • Completion of the Minimum Data Set-Home Care (MDS-HC)
  • Facilitation of member and caregiver access to community resources relevant to the member's needs, including referrals to Adult Day Health, Adult Foster Care and the Personal Care Attendant Program.
  • Participation in routine primary care team meetings
  • Pro-active management and follow-up (via home visits and by telephone) according to the member's care plan
  • Management and coordination of all transitions of care, including: Communicating care plan to providers in all settings of care (ED, hospital, rehabilitation facility, nursing home, home care) and ensuring providers receive timely clinical data that may impact healthcare treatment decisions, Direct caregiver supportServes as a member advocate and facilitator to resolve issues that may be barriers to care, Provide education and coaching to the member, family, and/or caregiver about health status, treatment options, goals of care, and health insurance benefits to assist members in making the most informed decisions and help promote self-management

    Knowledge/Skills/Abilities :


    • Bachelor of Science in Nursing (BSN)
    • Registered Nurse with current, unrestricted MA state license is required.
    • Minimum 3 years clinical nursing experience required
    • Experience in case management managing geriatric/chronic illness populations required
    • Experience within a SCO program highly preferred and/or VNA
    • Experience in Medicare and/or Medicaid managed care preferred
    • Proficient in computer use, the Internet, and health information technology required
    • Case management certification a plus

Keywords: Impresiv Health, Boston , RN Case Manager, Executive , Boston, Massachusetts

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