Care Manager (MA / Field-based)

Department & Position Overview:

FreedomCare’s Massachusetts operations support the MassHealth Adult Foster Care (AFC) program, which helps eligible adults with medical, physical, cognitive, or behavioral health needs receive daily assistance in a home setting from a qualified caregiver with professional care team support.

The Care Manager is responsible for conducting initial home assessments to determine eligibility for Home Health functional scale services as well as completing required monthly and quarterly in-home visits to assess the quality of our care and provide education to our caregivers to optimize our service levels.

This role combines in-home assessments with ongoing visits to monitor patient and caregiver well-being, ensuring safety, compliance, and quality of care. The Home Health Assessor works closely with the Care Team to communicate any concerns related to the patient’s or caregiver’s health, safety, or unmet needs to clinical for follow-up and care coordination.

Every Day You Will:

• Conduct in-home assessments for initial and ongoing evaluation of caregiver’s quality of care and skill proficiency, assessment of patient care needs, and ensure they are being care for in a safe and qualified setting.
• Provide coaching and education to our caregivers to optimize our service levels, through in-person demonstrations as well as the administration of self-guided trainings within our learning management system.
• Support consumer with service questions, goals, barriers, resources, and next steps while staying within non-clinical scope unless licensed.
• Document coaching interactions, outcomes, risks, referrals, and follow-up tasks in required systems.
• Develop, implement, evaluate, and revise client’s plan of care to include the physician’s plan of treatment, and problem list.
• Identify barriers related to care continuity, engagement, adherence, social needs, or customer experience.
• Maintain required call, outreach, quality, documentation, and follow-up standards.
• Coordinate care with written documentation and communication with the Care team, Clinical, Physicians, and leadership teams for escalation or handoff.
• Use empathy, motivational communication, and culturally responsive support during customer interactions.
• Escalate safety, clinical, compliance, or urgent customer concerns according to process.

Ideal Candidate Will Possess:

• A bachelor’s degree, a Massachusetts social worker license, and at least two years of recent experience working with elders or adults with disabilities; or a bachelor’s degree and two years of clinical experience caring for elders or people with disabilities.
• A negative tuberculosis screening result.
• 2+ years of health coaching, care coordination, patient support, or community health experience preferred.
• Valid driver’s license and insurance, with reliable means of transportation.

Qualifications:

• Demonstrated commitment to providing a high level of customer service, with the ability to communicate with empathy, patience, professionalism, and respect.
• Strong active listening skills, with the ability to understand patient needs, clarify concerns, and provide the necessary support and escalation when appropriate.
• Effective verbal and written communication skills, with the ability to clearly summarize interactions, document case activity, and communicate case status and next steps.
• Strong coaching and listening skills with the ability to build trust and provide comfort discussing sensitive barriers.
• Strong typing and computer proficiency, with the ability to efficiently navigate contact center technology, customer relationship management systems, and other necessary software applications while accurately documenting interactions.
• Effective problem-solving and critical thinking, with the ability to evaluate information, identify appropriate solutions, exercise sound judgment, and escalate concerns when necessary.
• Dependable and punctual, with a demonstrated commitment to consistent attendance, schedule adherence, and performance expectations.
• Ability to adapt to changing priorities, processes, systems, and business needs in a fast-paced environment.
• Receptive to coaching and feedback, with the ability to apply guidance and demonstrate continuous improvement.
• Ability to collaborate effectively as part of a team while working independently within established guidelines.