Home Health RN Case Manager
Tufts Medicine
Home Health RN Case Manager
Tufts Medicine
Integrated health system delivering connected care
Job Profile Summary
This role focuses on providing professional and nonprofessional nursing care services in accordance with physician orders. In addition, this role focuses on performing the following Home Care Nurse duties: Assesses, plans, implements, and evaluates the care needs of a designated group of patients or provides nursing care and identified clinical support tasks within the scope of practice for achievement of the patient’s plan of care as directed. Provides professional nursing care to patients. Requires a nursing license. A professional individual contributor role that may direct the work of other lower level professionals or manage processes and programs. The majority of time is spent overseeing the design, implementation or delivery of processes, programs and policies using specialized knowledge and skills typically acquired through advanced education. A senior level role that requires advanced knowledge of job area typically obtained through advanced education and work experience. Typically responsible for: managing projects / processes, working independently with limited supervision, coaching and reviewing the work of lower level professionals, resolving difficult and sometimes complex problems.
Job Overview
Utilizing the nursing process, the Home Health Registered Nurse will manage and deliver comprehensive home health services, including assessments, interventions, and supportive care to clients within their place of residence. Depending on the circumstances, duties may also include telephone triage, problem solving, patient/caregiver advocacy and support, with emphasis of avoiding hospitalization. As a key member of the health care team, this position must interact courteously and effectively with patients and their families as well as with co-workers from all Agency departments, community resources, and with patients' physicians in order to facilitate safe and efficient patient care while maintaining their own safety in the home and the community at large.
Job Description
Minimum Qualifications:
1. Candidates must hold an active RN license in the state where services are provided and may not work in states where they are not licensed. If additional state licensure is required, it must be obtained within sixty (60) days.
2. Valid state issued Driver’s License.
3. One (1) year of acute medical/surgical nursing experience.
4. Basic Life Support Certification.
5. If hired prior to 9/28/2026, CPR Certification is required upon hire. If hired after 9/28/2026, BLS Certification is required within thirty (30) days of hire.
Preferred Qualifications:
1. Bachelor of Science in Nursing (BSN).
2. Specialty nursing certifications.
3. Three (3) years of acute nursing including medical/surgical, oncology, hospice, or home health.
4. Experience with IV and complex wound care.
Hours: Full Time, 40 Hours/Week. Weekend/Holiday Commitment
Location: Newburyport, Amesbury, Salisbury, Merrimac, MA.
Duties and Responsibilities: The duties and responsibilities listed below are intended to describe the general nature of work and are not intended to be an all-inclusive list. Other duties and responsibilities may be assigned.
1. Assesses patients' physical, psychosocial needs in a sensitive, caring manner following established Standards of Nursing Practice and Agency policies and procedures. Provides ongoing interdisciplinary assessment of the patient.
2. Assesses patient/family learning needs, style and limitations and makes adjustments for delivery of information.
3. Recognizes/identifies patients/caregivers’ cultural beliefs re: death and dying and is sensitive to those beliefs.
4. Establishes realistic goals and develops plan of treatment in cooperation with the patient, family and members of the health care team.
5. Identifies abuse and/or neglect and identifies reporting mechanism per policy.
6. Adapts to new and unusual situations without affecting work performance negatively. Utilizes Security when and if needed for any potential unsafe situations.
7. Collaborates with patient /family and other health care providers and/or community resources with planning of care and discharge.
8. Continuously assesses/evaluates patient and family progress and goal achievement, keeping Clinical Manager advised and justifying continuation and/or termination of services.
9. Documents patient data, activities, and communications in patient record using computer system in a timely, organized, concise manner to ensure compliance with legal, certification, third party payor guidelines and Agency policies.
10. Completes physicians' orders, levels of care, and OASIS on all patients assigned, in accordance with patient care policies. Reconciles medications with patient and physician consistently.
11. Demonstrates and practices according to safety guidelines and procedures including general ergonomics, fire, and personal safety. Utilizes proper body mechanics and patient material handling.
12. Demonstrates an awareness of safety and security issues by responding appropriately to emergency situations and following established procedures and protocols utilizing stabilizing techniques.
13. Demonstrates ability to cope with patient/family emotional stress and provide appropriate supportive care.
14. Effectively manages assigned caseload, within the team model of care delivery. Establishes a daily work plan based upon patient/family priorities of service and total area needs. Promptly triages patient visits, messages, and phone calls according to priority and urgency.
15. Provides nursing coverage on a rotating basis for evenings, nights, weekends and Holidays.
16. Demonstrates excellent physical assessment and care planning skills. Demonstrates current knowledge of pharmacology and medication administration and reconciliation.
17. Coordinates care and discharge planning with other team members during case conferences.
18. Acquires and maintains an expert working knowledge of all third part payers and regulatory bodies and agency policies on issues related to documentation and care provided.
19. Communicates and collaborates with all disciplines in the home care setting on a regular basis or immediately if there are any critical needs or crisis interventions needed.
Physical Requirements:
1. While performing the duties of this job, the employee is required to stand; walk; sit; use hands to finger, handle, or feel objects, tools or controls; reach with hands and arms; climb stairs; balance; stoop, kneel, crouch or crawl; talk or hear; taste or smell.
2. The employee must regularly lift and/or move 25 lbs and occasionally lift and/or move up to 100 lbs.
3. The employee in this position frequently communicates internally and externally.
4. Must be able to exchange accurate information via phone, email and/or in person.
5. Specific vision abilities apply including close vision, distance vision and ability to adjust focus.
6. Noise level in the work environment is usually moderate.
7. May be exposed to weather conditions prevalent at the time.
Skills & Abilities:
1. Demonstrates knowledge and skills necessary to provide care appropriate to the age of the patients served.
2. Demonstrates competence in Home Health and Hospice standards of care, symptom management, psychosocial, and spiritual aspects of care.
2. Excellent interpersonal skills with the ability to communicate, read, and write in English.
3. Ability to function well, effectively manage time, and prioritize busy schedules.
4. Good organizational skills.
5. Ability to function effectively, autonomously, and independently in a home care setting.
6. Ability to function effectively and autonomously in a home care setting.
What We Offer
About Care at Home:
Tufts Medicine Care at Home is a proud member of Tufts Medicine, a health system that is rethinking how academic and community centers, local and national businesses, and technology and service innovators can all work together. So that clinicians can deliver expert care where it’s needed most and so that we can bring wellness back to health care, one person at a time.
About Tufts Medicine
A healthcare system that works Tufts Medicine is more than a health system — we’re a community that empowers people to live their best lives by reimagining healthcare, advancing knowledge and pioneering discovery. Every team member plays an integral role in realizing our vision of creating the most equitable and frictionless healthcare experience in the world. Here, you’ll join an enthusiastic community that champions your growth and receive generous benefits to support you and your family’s well-being.
Tufts Medicine is an equal opportunity employer
At Tufts Medicine, we want every individual to feel valued for the skills and experience they bring. Our compensation philosophy is designed to offer fair, competitive pay that attracts, retains, and motivates highly talented individuals, while rewarding the important work you do every day.
The base pay ranges reflect the minimum qualifications for the role. Individual offers are determined using a comprehensive approach that considers relevant experience, certifications, education, skills, and internal equity to ensure compensation is fair, consistent, and aligned with our business goals.
Beyond base pay, Tufts Medicine provides a comprehensive Total Rewards package that supports your health, financial security, and career growth—one of the many ways we invest in you so you can thrive both at work and outside of it.
Pay Range:
$84,300.22 - $107,481.20based on full-time equivalent
Integrated health system delivering connected care
Tufts Medicine is an integrated health system in Massachusetts that brings together academic medical centers with community hospitals, a large home care network, and a wide physician network to coordinate care. It operates by aligning hospitals, doctors, and home care under a single strategy so patients can move smoothly across settings and receive consistent, lower-cost care. Its differentiator is the combination of academic medicine with broad community care and a focus on connected, low-friction patient experiences. The goal is to provide the highest quality care at the lowest possible cost, expand access, and transform how people engage with healthcare.
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