Assessment Nurse Case Manager

Fallon Health

. Conduct face-to-face home visits for new enrollees within 30 days of enrollment .

Posted 11/9/2026full-timePlymouth • Massachusetts • United StatesJunior💰 $95,000 - $100,000 per yearWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in conducting comprehensive health assessments, including in-person and telehealth evaluations, while collaborating effectively with interdisciplinary teams. Holds a strong foundation in regulatory requirements and case management principles to support quality care initiatives.

Highest-signal resume keywords

Registered Nurse License in MassachusettsClinical RN Experience with Complex Medical ConditionsCertification in Case ManagementExperience with OASIS/MDS AssessmentsStrong Communication and Interviewing Skills

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Health Risk AssessmentMedication ReconciliationFunctional AssessmentLTSS EvaluationRegulatory AssessmentTelehealth AssessmentMotivational InterviewingCulturally Sensitive InterviewingAssessment Tool CompletionProblem-Solving Skills

Soft Skills

Strong Communication SkillsAdaptabilityInterdisciplinary Team Collaboration

Tools & Technologies

Integrated Time-for-Task ToolNaviCare Case Management Program

Certifications & Qualifications

Registered Nurse LicenseCertification in Case Management

Industry Keywords

Home HealthMedicareMedicaidHEDIS5 Star RatingSocial Determinants of HealthFace-to-Face Member Interactions

About the role

Key responsibilities & impact

Conduct face-to-face home visits for new enrollees within 30 days of enrollment
Onboard members and complete regulatory assessments
Complete in-person Health Risk Assessments according to assigned frequency
Complete new Personal Care Attendant assessments using the integrated time-for-task tool and yearly PCA reevaluations
Submit yearly MDS assessments and assessments following significant changes in status
Conduct home visits for onboarding and regulatory assessments
Provide education on the NaviCare case management program
Conduct telephonic, virtual, and telehealth assessments when appropriate
Collaborate with the Care Team and Utilization Management
Complete LTSS evaluations
Conduct in-home assessments using motivational and culturally sensitive interviewing
Perform medication reconciliation
Complete state-required assessment tools per contract
Conduct functional assessments for LTSS programs
Participate in training and audits
Maintain program and policy knowledge to educate members
Support HEDIS, Medicare 5 Star, and other initiatives

Requirements

What you’ll need

Graduate from an accredited school of nursing mandatory
Active, unrestricted license as a Registered Nurse in Massachusetts
Certification in Case Management strongly desired
Valid driver's license
Must attest to no disqualifiers per Driver Safety Policy
Proof of minimal state-required auto insurance
Reliable transportation
1+ years of clinical RN experience with complex medical, behavioral, and social co-morbidities
Ability to conduct assessments in-person and via telehealth
Ability to work on interdisciplinary teams
Skill in screening social determinants of health
Strong communication and interviewing skills
Problem-solving skills and adaptability
Knowledge or willingness to learn regulatory requirements
Preferred experience with Home Health, OASIS/MDS, Medicare/Medicaid, and face-to-face member interactions
Reliable home internet
Bachelor's or advanced degree in nursing or a health care related field preferred

Benefits

Comp & perks

Equal employment opportunities and protection from discrimination and harassment
Reliable home internet requirement/support implied for hybrid work