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Family Service Association - Fall River Wellness Nurse Case Manager in Fall River, Massachusetts

We llness Nurse Case Manager

Family Service Association is a comprehensive private, non-profit social service agency dedicated to the development and implementation of services designed to provide strength and support to individuals and families throughout southeastern Massachusetts. Headquartered in Fall River, Family Service Association strives to increase the capacity of individuals and families to cope with the stresses of family life and interpersonal relationships in a positive, productive and health-improving manner. This agency is a leading provider of professional social services in the South Coast region of Massachusetts, with a 130-year tradition of high quality.

Sign on Bonus $2,000

We have an exciting opportunity in a new program initiative at Family Service Association. We are seeking a full time (35 hours per week), Monday through Friday, 9:00 a.m. - 5:00 p.m., Wellness Nurse Case Manager in our Long-Term Support Service Community Program (LTSS CP).

The Long Term Services and Supports (LTSS) Community Partners (CP) Care Integration and Wellness Nurse Case Manager is responsible for assisting the Care Coordination teams to enhance coordination in the delivery and receipt of services to enrollees assigned by Accountable Care Organizations (ACO) and Managed Care Organizations (MCO), or Mass Health.

Duties and Responsibilities:

  • Respect the confidential nature of all program services and communications therewith.

  • Assist with enhancing program’s ability to capture demographic information, interpret all data, including gaps in care, to determine where disparities exist in order to address them.

  • Provide consultation and support care coordination teams whose assigned members have identified wellness goals to discover and break-down barriers to positive health outcomes.

  • Assist Care Coordinators with developing care plan goals that address health disparities.

  • Provide training and support to Care Coordinators to enhance their ability to support the wellness goals of their members, including strengthening of health and wellness coaching, use of SBAR, understanding risk factors, etc.

  • Provide case consultation and / or attendance at Integrated Case Conferences for members with complex medical and / or SDOH needs.

  • Assist with transitions of care for members with complex health needs, including but not limited to, being lead point of contact to assure integrated care between ACO / MCO, PCP, CP staff, providers and other team members.

  • Provide outreach to hospital or emergency departments to develop relationships in order to facilitate gathering of information, including discharge summaries, and create glide paths for transitions of care, and continued integration.

  • Maintain all documentation required for the delivery of LTSS Community Partners services including other data entry into EHR as required.

  • Attend regular supervisory meetings both on a team and individual basis as required

  • Participation in on-going CQI activities.

  • Respond to reasonable expectations of the Agency and/or supervisor.

    *Family Service Association is offering a $2,000 Signing Bonus * Education and Experience:

    Must be a Registered Nurse with current license for the state of Massachusetts in good standing as well as possess experience in dealing with youth and adults, individuals with complex medical needs, and disabled populations.

This is a benefits eligible position. Benefits include medical, dental, vision, short term and long term disability insurance, life insurance, 403(b), flexible spending account and a generous time off package including paid vacation, ten sick days accrued annually with rollover and twelve paid holidays. We offer ongoing training opportunities and an excellent work environment.

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