Assessment Nurse Case Manager

Fallon Health

. Conduct home visits for onboarding and regulatory assessments .

Posted 11/6/2026full-timeWorcester • Massachusetts • United StatesJunior💰 $95,000 - $100,000 per yearWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in conducting comprehensive assessments, including Health Risk Assessments and functional evaluations, while collaborating effectively with interdisciplinary teams. Holds a strong understanding of regulatory requirements and case management principles, with a focus on delivering quality care in home health settings.

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 AssessmentsMedication ReconciliationFunctional AssessmentsTelehealth AssessmentsInterdisciplinary Team CollaborationRegulatory KnowledgeScreening Social Determinants of HealthLTSS EvaluationsPersonal Care Attendant AssessmentsMDS Assessments

Soft Skills

Problem-Solving SkillsAdaptabilityStrong Communication SkillsCulturally Sensitive InterviewingEducation and Training Skills

Certifications & Qualifications

Registered Nurse LicenseCertification in Case Management

Industry Keywords

Home HealthMedicareMedicaidHEDIS5 Star RatingFace-to-Face Member InteractionsLTSS ProgramsDriver Safety PolicyAuto Insurance RequirementsInterdisciplinary Care Team

About the role

Key responsibilities & impact

Conduct home visits for onboarding and regulatory assessments
Complete face-to-face home visits for new enrollees within 30 days of enrollment
Complete in-person Health Risk Assessments (HRAs) according to assigned frequency
Complete new Personal Care Attendant (PCA) assessments using the integrated time for task tool and yearly PCA reevaluations
Submit yearly and significant-change MDS assessments accurately and on time
Conduct telephonic or virtual assessments when appropriate
Provide education on the NaviCare case management program
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
Must possess a valid drivers’ license
Must attest to no disqualifiers per Driver Safety Policy
Must possess and provide proof of minimal state required auto insurance
Must have reliable transportation
1+ years of clinical RN experience with complex medical, behavioral, and social co-morbidities
Ability to conduct assessments in-person and 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: Home Health, OASIS/MDS, Medicare/Medicaid, face-to-face member interactions
Reliable home internet