The Registered Nurse Care Manager (RN) works collaboratively as part of a care management team to assess consumer needs, establish a person-centric plan of care, conduct regularly scheduled home visits. The RN coaches, advocates and educates caregivers to assist with the daily health and well-being needs of consumers.

• Completes and coordinates all applicable clinical assessments and clinical evaluations
• Trains, evaluates and supports Caregivers in conjunction with the care manager as needed on an on-going basis
• Coordinates consumer placement following acceptance to program and ensures that all required forms and standard procedures are followed for the placement process. Conducts orientation training for each caregiver before the caregiver enters the program as well as on-going training.
• Provide ongoing coaching to drive effective utilization of established best practices and protocols (carepaths) where appropriate
• Works collaboratively to develop and review on an ongoing basis, each members plan of care
• Reviews the caregiver notes daily and appropriately addresses changes in the consumers condition or environment
• Completes nursing progress note corresponding with each on-site visit or encounter, or more often as the members condition warrants
• Submits semi-annual health-status reports to each members PCP based on regulatory requirements
• Monitors the health status of all members to ensure that all needed AFC is properly delivered
• Reports changes in health status of any member to the members Primary Care Physician
• Coordinates the implementation of physicians orders with the consumer, caregiver and other team members
• Plans and implements discharges and transition from the AFC program
• Ensures continuous survey readiness and compliance with accepted professional standards and practices and federal/state/local regulations including fraud, waste and abuse prevention; HIPAA and similar regulations; occupational safety and health standards; and company policies, procedures and performance standards.
• Perform other duties as assigned.

• Must hold an active Registered Nurse (RN) License in the state of employment
• Minimum two (2) years of recent experience in direct care of elders or adults with disabilities
• Ability to travel (usually by automobile) within assigned geographic area; valid drivers license and automobile insurance is required
• Experience in case management, care planning and assessment for cases including but not limited to eldercare, people with disabilities, and other complex medical needs in a health care setting
• Proficiency in common software and web-based applications (e.g. MS Office, case management systems)
• Additional state-specific qualifications may be required.

Careforth empowers thousands of family caregivers across the United States to confidently care for their loved ones at home. Everyday our team of trained nurses and care coaches engage in real conversations with caregivers, personally and via our proprietary digital collaboration app, to provide emotional support, personal guidance, and connections to community resources. Headquartered in Boston, Careforths caregiver programs and services improve health outcomes, provide cost savings for those receiving care, and increase engagement and satisfaction for health plans and providers. Through it all Careforth supports family caregivers. At every turn.

For more information, please visit www.Careforth.com.

Careforth is an Equal Opportunity Employer*

DISCLAIMER: Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job.

*Careforth supports families with diverse backgrounds and as an equal opportunity employer, we seek employees who reflect the diverse population we serve. Careforth complies with all applicable laws concerning hiring and employment practices and is firmly committed to fostering and maintaining a workplace free from discrimination. We pledge to hire, train, and promote our employees without regard to race, religion, gender, gender identity, genetic information, age, national origin, sexual orientation, disability, veteran status, or any other category protected by applicable law.

Careforth strives to create experiences that are accessible and welcoming to everyone, including making www.careforth.com and the careers site accessible to any and all users. If you would like to contact us regarding the companys diversity, equity and inclusion initiatives, inquire about a specific accessibility need or the accessibility of our website, or if you need assistance completing an application process, please contact People & Culture at 866-797-2333.