Registered Nurse Case Manager, RN

Title: Healthcare Coordinator

Department: Residential Services

Hours Expected: 20-40 hours per week

Expected schedule: Monday through Friday, 6 hours per day

Reports directly to: Residential Nursing Supervisor

Nonexempt

Summary: Registered Nurse in this role provides compassionate care to adults with developmental, intellectual and/ or physical disabilities. The Nurse will provide care coordination and clinical oversight. This role will work with individuals in various Residential homes.

Health assessment and monitoring

• Completes initial record review for each new individual to identify health needs. This includes new referrals
• Monthly reviews the health status of assigned individuals through observation, interviews and documentation.
• preventative screening, annual vaccines
• Follows up with doctor’s office for test results and health related data.
• Completes an annual health assessment for assigned individuals’ ISP
• Reviews health-related data from skilled assessments, labs, doctor visits and patient portals and documents updates on SharePoint.
• Assess individuals' ability to self-medicate and provide appropriate guidance.
• Conduct on-site health assessments and treatments as needed.
• Provide support to other homes or individuals outside primary assignment as directed by the Residential Nursing Supervisor or Residential Director 

Health Care Coordination and oversight.

• Confers with medical, administrative, and other staff to determine individuals’ health needs.
• Create and revise clinical health care protocols for assigned individuals.
• Consults on health services and adjusts care and services in conjunction with providers as needed. This includes PT, OT, Speech, Dietician, Hospice etc.
• Ensures effective implementation of the Health Care Regime through staff training and evaluation of competency.
• Maintains and coordinates components of health care to be in compliance with survey and certification, MAP, state, federal and DDS regulations.
• Respond to health/ safety emergencies and ensure proper referrals. This includes participating in risk meetings with the management team and DDS.
• Ensures appropriate follow-up after individuals’ hospitalization, communication with hospitalists and coordinating transition of care during discharge. Follows up for compliance on post-discharge referrals like VNA and specialists.
• Consult with the manager on complex medical appointments and case conferences as needed.
• Ongoing assessment on the need for healthcare equipment, communicate need for PT/OT referral
• Complete the health-related supports and protective equipment authorization form and share with the assigned manager.

Communication and team collaboration

• Consults with individuals, families, guardians, house managers and staff to address needs and care strategies.
• Establishes and maintains strong communication with managerial and supervisory staff. Collaborates with management to resolve issues impacting individuals’ health and quality of life.
• Complete required health care documentation for ISP meeting. Consult with manager on potential healthcare related ISP goals prior to meeting.
• Participates in house meetings, medication review meetings and nursing meetings.

Education, Training and Staff Support

• Functions as a health care resource for staff, individuals, families and guardians.
• Assess the need for new training or re-training and coordinate trainings.
• Collaborate with the training department to ensure training compliance and documentation of training on electronic platform (SharePoint).
• Enhances individuals’ health and independence through education and quality interaction.
• Provides training on specialized clinical protocols, e.g. G-Tube, catheter, O2, etc.
• Participates in in-services training and keeps current with healthcare trends and licensure requirements.
• Conduct MAP training and MAP recertifications, as needed and to fulfill MAP TTT requirements.
• Attend educational seminars provided through DDS e.g. Annual RN conference

Professionalism and Ethics

• Acts a positive role model
• Participates in continuing education
• Performs other related duties as assigned
• Interpersonal Skills: Builds positive relationships and communicates effectively across all levels.
• Teamwork & Cooperation: Works collaboratively with team members and leadership to achieve goals.
• Dependability: Completes responsibilities with accuracy and reliability.
• Communication: Clearly conveys information in both individual and group settings.
• Planning & Organization: Prioritizes multiple tasks efficiently and adapts to changing conditions.
• Initiative & Problem-Solving: Demonstrates self-reliance and critical thinking in decision-making.
• Management & Leadership: Leads, by example, supporting and enforcing agency policies.
• Data Collection & Reporting: Gathers, compiles, and presents accurate reports in a timely manner.

Qualifications

• Education: Registered Nurse
• Licensure: Active Registered Nurse (RN) license in Massachusetts.
• Experience: Minimum one year of nursing experience in a healthcare facility, school, or community setting.
• Preference for experience with developmental disabilities, nursing homes, or DDS/DPH regulations.
• Training Certification: Ability to obtain Medication Administration Program (MAP) Trainer Certification within six months of employment.
• Legal & Compliance: Must authorize Criminal History Background Check (CORI) and release information from DPPC, DDS, and other regulatory agencies.
• Physical Ability: Capable of performing essential job duties, with reasonable accommodation as needed.
• Driver’s License & Transportation: Valid Massachusetts driver’s license and access to reliable transportation.
• Technical Skills: Proficient in Microsoft Office applications, SharePoint, Outlook, Teams and electronic health records (EHR).

Physical Demands/Work Environment: 

• Ability to provide direct care in activities of daily living (bathing, dressing, eating, toileting, and continence, transferring and mobility) as needed.  
• Ability to lift, push and pull up to 50 pounds. 
• Ability to assume and maintain a variety of postures (kneeling, squatting crawling, sitting, and standing) for extended periods of time. 
• Ability to safely operate a motor vehicle and accessible van lift. 
• This role uses standard office equipment such as computers, phones, photocopiers, filing cabinets and fax machines. 
• Safely transport oneself to and from appointments and other scheduled meetings. 

Professional Development/Training Offered: 

• Complete required Continuing Education Units to maintain Nursing Licensure. 
• Minimum of 20 hours of training (both live and/or online) annually as assigned by supervisor, including required CEU hours.  
• Complete Medication Administration Program Train the Trainer Program within 90 days of hire. 
• Hold and maintain certification in CPR and Safety Care

Job Types: Full-time, Part-time

Pay: $40.00 per hour

Expected hours: 20.0 – 40.0 per week

Benefits:

• 401(k)
• Dental insurance
• Employee assistance program
• Flexible schedule
• Flexible spending account
• Health insurance
• Life insurance
• Paid sick time
• Paid time off
• Referral program
• Retirement plan

Experience:

• Group home: 1 year (Preferred)
• MAP: 1 year (Preferred)
• Nursing: 1 year (Required)

License/Certification:

• Driver's License (Required)
• Registered Nursing license in the state of MA? (Required)

Work Location: In person

Salary : $40