Case Manager

Position Summary

Coordinate comprehensive case management, psychosocial support, caregiver oversight and access to community resources for assigned members. Partner closely with nursing and Operations to support safe, consistent services, proactive problem resolution and strong member and caregiver outcomes.

Case Management and Member Assessments

• Receive and acknowledge the RN admission handoff, coordinate the case-management-first monthly cadence and complete assigned routine, semiannual and annual case management visits in their required windows.
• Complete and update social histories, psychosocial assessments and evaluations of the qualified setting, including fire and safety procedures, environmental concerns and ongoing suitability.
• Identify changes in member needs, family circumstances, caregiver capacity, social supports and potential barriers to ongoing services; coordinate timely interventions.
• Participate in developing, implementing and reviewing the plan of care with the member, caregiver, RN and other involved professionals while maintaining distinct case management responsibilities.

Caregiver Support, Education and Retention

• Provide practical caregiver guidance, reinforce approved care-plan expectations and help address concerns before they escalate into disruptions or discharge.
• Partner with Caregiver Experience and regional leadership to identify at-risk cases, coordinate recovery plans and track interventions and outcomes.
• Review assigned caregiver logs at least every 30 days, including months without a home visit; address missing or inconsistent information through the established process.
• Support coordination of primary and alternate caregiver changes with nursing, credentialing and scheduling, ensuring proper handoffs before service changes.

Resources, Referrals and Transitions

• Connect members and caregivers with appropriate health, social and community resources; document referrals, assigned follow-up and results.
• Coordinate with nursing on clinical concerns that require RN review; promptly communicate changes in member status, safety risks or unmet needs.
• Participate in multidisciplinary case conferences, transitions and discharge planning, including communication of outstanding needs and continuity risks.

Interdepartmental Collaboration and Service Coordination

• Coordinate with Regional Operations, nursing, Caregiver Experience, Scheduling, Credentialing, Medical Records and Compliance to resolve service barriers and ensure accurate handoffs.
• Document escalations, identify accountable owners and follow through until issues are resolved; communicate emerging risks before they interrupt services.
• Collaborate directly with Scheduling to coordinate required home visits, member and caregiver availability, timely follow-up and efficient geographic routing; communicate cancellations, access barriers and changes promptly.
• Evaluate and document whether each member's home remains a qualified and appropriate setting, including household safety, fire preparedness, emergency procedures, accessibility and caregiver readiness; escalate deficiencies and help coordinate corrective actions.
• Provide ongoing case management support by identifying psychosocial and practical barriers, facilitating community resources, addressing caregiver concerns and tracking action plans through resolution.
• Partner with the RN and regional leadership to translate field observations, home-preparedness findings and caregiver feedback into individualized care plans and timely updates.

Documentation, Systems and Quality Improvement

• Maintain timely, accurate and complete records in approved systems, including assessments, visits, communications, outstanding actions and resolutions.
• Follow established standard operating procedures, confidentiality requirements and documentation standards; identify recurring gaps and recommend practical workflow improvements.
• Participate in quality reviews, required training, competency evaluations and periodic field shadowing; use performance data and feedback to improve service quality.

Field Operations, Case Insight and Leadership Collaboration

• Perform duties primarily in members' homes and other assigned field locations.
• Build professional, supportive relationships with members and caregivers through in-person visits; listen to concerns, provide practical guidance within role scope and ensure issues reach the appropriate team promptly.
• Work directly with the Regional Manager and Regional Director to share meaningful case observations, caregiver concerns, service barriers and opportunities to improve member outcomes and continuity of care.
• Provide timely, actionable case insights to the RN, Regional Manager, Regional Director, and other appropriate clinical and operational leaders, as applicable, and contribute to the development, implementation, and review of individualized plans of care within professional scope.
• Plan field visits geographically and coordinate schedules to reduce unnecessary travel, protect member-facing time and meet required visit windows without compromising care quality.
• Maintain accurate mileage records and submit mileage expense reports with required trip details, supporting documentation and approvals in accordance with company policy; promptly resolve discrepancies.
• Keep field notes, case updates and follow-up assignments organized in approved systems; communicate key findings and outstanding needs across departments while safeguarding confidential information.

Qualifications and Requirements

• Bachelor's degree and qualifications consistent with the applicable MassHealth Adult Foster Care case-management requirements; HR and Compliance must verify the qualifying pathway before assignment.
• Where the qualifying pathway requires a Massachusetts social-work license or relevant experience, maintain the applicable credentials and experience; regulatory substitutions require prior approval when applicable.
• Strong psychosocial assessment, case coordination, resource-navigation, communication and documentation skills.
• Ability to travel to member homes and community settings; valid driver's license and reliable transportation where driving is required.
• Maintain CPR certification as required by Vitra Health.
• Proficiency with Microsoft Office applications, mobile devices and electronic documentation systems.
• Employment is contingent upon successful completion of all required pre-employment screenings, including background checks, reference checks and any program, contractual or regulatory requirements applicable to the position.