SCO RN Case Manager

Position Title: Senior Care Options (SCO) RN Case Manager

Department: Senior Care Options

Supervisor: SCO Clinical Coordinator

Hours per week: 40 hours

Status: Non-Exempt

Primary Function:

The SCO RN Case Manager provides direct services to patients along with consultations to staff and families in accordance with health center policies and professional standards. Responsibilities are focused on providing individualized clinical case management services to SCO patients. This includes: comprehensive assessment, referrals to necessary services, ongoing support, follow-up and coordination with primary care providers and specialists. The SCO RN Case Manager is responsible for the evaluation of patients and provides monitoring and follow-up, executes physician's orders as required and must be professionally responsible to nurse practitioners, the Medical Director and the Operations Manager.

Duties & Responsibilities:

• Conduct comprehensive MDS (Minimum Data Set) assessments in accordance with CCA SCO and state regulatory requirements.
• Complete PCA (Personal Care Attendant) assessments to determine eligibility and level of need for home-based assistance.
• Perform in-home nursing assessments to evaluate medical, cognitive, functional and psychosocial status.
• Identify changes in member condition and update care plans accordingly.
• Develop individualized, person-centered care plans based on assessment findings, clinical judgment, and member goals.
• Coordinate care with providers, specialists, long-term support services, community agencies, and family caregivers.
• Participate in interdisciplinary team meetings to present assessments, care plans, and updates
• Monitor the effectiveness of interventions and adjust plans as needed to promote safety, independence, and optimal health outcomes.
• Complete all assessments, care plans, visit notes, and documentation within established timeframes.
• Maintain compliance with state regulations, CCA SCO program guidelines, HIPAA, and organizational policies.
• Provide primary clinical case management for patients through collaboration with SCO team (enrollment coordinator, physician, GSSC and nurse practitioner/physician assistant).
• Deliver patient care/patient education in an appropriate manner according to age, physical ability, educational level and culture.
• Conduct health assessments and evaluate the needs of patients in the primary care clinic and in the home setting
• Conduct physical exams, order and/or perform laboratory and diagnostic tests, and make clinical judgments regarding results. (The SCO nurse practitioner/physician assistant or the primary care provider will provide clinical back-up as needed).
• Participate in trainings provided by CCA.
• Follow CCA/UCC documentation requirements.
• Comply with CCA/UCC guidelines and changing regulations as needed.
• Participate in development of comprehensive patient plan of care.
• Initiate appropriate consultation and referrals.
• Handle utilization management.
• Assist with Prior Authorizations management and fulfillment.
• Provide health information and teaching with emphasis on prevention and curative treatment.
• Act as primary care resource to the Multidisciplinary Team and provide in-services for staff.
• Participate in teaching activities with nurses, nurse practitioner, and medical students.
• Document history & physical, assessment and treatment intervention in record.
• Participate in committees for quality of care, standards of care, policies and procedures, and other program development activities.
• Always maintain patient confidentiality.
• Maintain current standards of practice and seek professional development.
• Participate in regularly scheduled clinical care, team, and department meetings.
• Develop and modify, when necessary, an individual care plan for each client based on the assessment above that identifies the needs of the client, and includes short- and long-term goals, objectives, specific services, providers giving care, time frames to reach each objective, and who will address unmet needs.
• Make home visits necessary to ensure that the services needed of the homebound enrolled are met.
• Perform other duties as required.

Minimum Basic Knowledge:

Licensed Registered Nurse (B.S.N. preferred) in Massachusetts.

Experience & Qualifications:

• Two years of nursing experience, ideally within a community health setting.
• Prior experience in a culturally diverse setting.
• Bilingual language skills in English plus Vietnamese, Spanish, Portuguese, or Cape Verdean Creole is preferred.
• Valid driver's license.

Essential Functions:

This position is a key member of the Senior Care Options (SCO) interdisciplinary team, responsible for assessing, planning, coordinating, and monitoring clinical and supportive services for older adult members. This role ensures members receive high-quality, person-centered care that supports safety, independence, and overall well-being in the community.

Physical Requirements:

• Must be able to remain in a stationary position 50% of the time.
• Must occasionally move about/inside the office, and move outside of the office environment to do home visits.
• Must be able to operate a computer and other productivity machinery.
• Must be able to position self to maintain files in the file cabinets.
• Must be able to communicate information and ideas so others will understand.
• Must be able to observe details at close range (within a few feet of the observer).

Supervisory Responsibility:

None

Define Access Level to PHI: Level 4: Authorized to access full health information. UCC position and job responsibilities involve the provision of patient care and working as a clinical team member. Staff in this category level, although allowed full access, should only access the necessary information for each respective treatment encounter/circumstance.