MA- Merrimack Valley/Lawrence- RN Case Manager

The Role

We're looking for a passionate Registered Nurse to join our team as a RN Case Manager. This role will report into the Director of Nursing in Massachusetts. This is a Full-Time opportunity based in the Merrimack Valley/Lawrence Area.

The RN Case Manager at Abby Care provides the comprehensive care and coordination of services for patients within their caseload. This role requires a nurse with excellent organizational skills, strong communication abilities, and a dedication to providing high-quality patient care. The RN Case Manager will work closely with patients, families, Primary Care Physicians (PCPs), therapy providers, and internal support teams to ensure optimal patient outcomes.

Key Responsibilities:

• Patient Care and Coordination:

  • 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.

• Clinical Documentation:

  • 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.

• Communication and Collaboration:

  • 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.

• Quality Assurance:

  • 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.