MA - Worcester County North/Fitchburg - RN Case Manager

We envision a future where family-led care is a core part of the healthcare system. Abby Care is building that future. Join us in solving one of the most important challenges of our time. 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 Worcester County North/Fitchburg 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. The Requirements: An Associate's Degree or A Baccalaureate School of Nursing Degree. Current and valid license as a Registered Nurse in the state of Massachusetts. Bilingual in spanish (preferred) 2 years of experience as a Registered Nurse in a clinical setting; 1 year of home health experience preferred. Case management/supervisor experience and pediatric/adult care experience preferred. Knowledge of Medicaid paid family caregiving program and HHA scope of prac