Company Overview
Hearth is a non-profit organization dedicated to the elimination of homelessness among the elderly. This mission is accomplished through a unique blend of prevention, placement, and housing programs all designed to help elders find and succeed in homes of their own. To this end, all housing operated by Hearth provides a creative array of supportive services that assist residents to age with dignity, regardless of their special medical, mental health, or social needs. Hearth believes these goals are best accomplished through respect for elders and staff, with the desire to see both achieve their highest degree of potential.
Position Overview:
The Nurse Care Manager is responsible for promoting and maintaining the physical and behavioral health of residents within Hearth’s supportive housing programs. This role provides clinical oversight, ensures residents receive timely access to appropriate healthcare services, and advocates for their overall well-being. The Nurse Care Manager coordinates with internal staff and external providers to optimize health outcomes and support aging in community.
Provides nursing oversight, health coordination, advocacy, and direct resident support, and supervises CNA and HHA staff within the program sites. Also oversees billing and service authorizations and coordinates with SCOs and health insurance providers. This position is responsible for reviewing and approving resident assessments and care plans conducted by the LPN Nurse Care Managers at various Hearth sites
Pay: :$94,500 Per year with $3,000 sign-on bonus paid in two installments: $1,500 after three months of employment and the remaining $1,500 after six months of employment.
Pay Transparency:
The above reflects the anticipated annual salary range for this position if hired to work in Massachusetts.
The compensation offered to the candidate selected for the position will depend on several factors, including the candidate's educational background, skills and professional experience.
This is a full-time position (40 hours per week) supporting two Hearth sites: Ruggles Assisted Living and Four Corners.
Major Functions:
1. Advocate for residents’ physical and behavioral health needs.
2. Educate residents on medical conditions, medications, and wellness practices.
3. Screen, investigate, and assist residents with enrollment into Senior Care Options (SCO) and other insurance-based care coordination programs.
4. Coordinate care among medical providers, pharmacies, home care agencies, and other healthcare professionals.
5. Ensure required and recommended medical appointments are scheduled, completed, and documented.
6. Monitor, document, and communicate changes in residents’ health status in the electronic record system (ETO & EVV & GAFC logs).
7. Oversee CNA and HHA performance and support continuing education through internal and external training platforms.
8. Oversee billing processes and service authorizations related to residents’ care coordination.
9. Accompany residents to medical appointments when necessary.
10. Attend monthly interdisciplinary and resident meetings, and participate in weekly on-site team meetings.
Duties and Responsibilities:
Assessment
· Complete comprehensive nursing assessments upon move-in, semi-annually & annually.
· Identify health risks, functional changes, and needed interventions.
· Develop, implement, and revise individualized care plans in partnership with the interdisciplinary team.
· Document all health-related updates, interventions, and changes promptly in the internal database (ETO, cx360, & EVV).
· Conduct reassessments following any significant change in condition, hospitalization, or incident.
· Update medication reconciliations after medical appointments, hospitalizations, or provider changes in the system.
Education & Advocacy
· Educate residents on diagnoses, medications, and self-management strategies.
· Train staff to recognize changes in residents’ conditions and follow appropriate reporting procedures.
· Advocate for residents to receive appropriate services, equipment, and care.
· Ensure compliance with DPH/CDC recommended vaccination guidance and support residents in obtaining required vaccinations.
· Support residents through transitions of care, including hospital discharge plans and specialty referrals.
· Facilitate monthly information sessions and trainings for residents on health and wellness topics (e.g., well-being, mental health, diabetes).
Care Coordination
· Maintain communication with physicians, specialists, therapists, pharmacists, visiting nurses, and care management agencies.
· Arrange and track annual PCP visits and follow-up appointments.
· Facilitate enrollment in SCO plans where appropriate.
Supervision of Personal Care Homemakers
· Provide oversight and direction Certified Nursing Assistants (CNA) & Home Health Aides (HHA), ensuring quality delivery of personal care services.
· Monitor documentation and adherence to resident care plans.
· Review schedules, attendance, and time-off requests; ensure adequate staffing coverage.
· Review and submit bi-weekly timesheets for all direct reports.
· Conduct bi-weekly team meetings to review resident needs and workflow updates.
· Complete annual & introductory 90-day performance evaluations, provide performance feedback, and address concerns related to professionalism, punctuality, and resident interaction.
· Support training and competency development as needed.
Education, Experience, and Licensure:
· Registered Nurse (RN) with a degree from an accredited School of Nursing (B.S. preferred) and a valid RN license in the state of MA
· Minimum of two (2) years clinical experience.
· Experience with PACE, Dementia, Elders, Persons with Disabilities, or Community Health Services preferred.
· Minimum of one (1) year supervisory experience preferred.
· Must maintain nursing license in good standing.
· Must maintain CPR, First Aid & AED certification.
Required Skills, Abilities and Knowledge
· Demonstrated ability to assess the behavioral health, social, and functional needs of older adults using evidence-based, trauma-informed, and person-centered approaches.
· Strong understanding of mental health conditions, substance use disorders, cognitive impairments, hoarding disorder, and other psychosocial issues common among aging and formerly homeless populations.
· Ability to develop, implement, and monitor individualized service plans, including collaboration with interdisciplinary teams, community providers, and external agencies.
· Proficiency in crisis intervention, de-escalation strategies, and safety planning, with the ability to identify risk factors and respond appropriately.
· Working knowledge of public benefits and entitlement programs, including Medicaid, Medicare, SSI, SSDI, SNAP, GAFC services, housing subsidies, and elder service systems.
· Excellent oral and written communication skills, including the ability to document services accurately and in a timely manner in electronic record systems (e.g., ETO, EVV, Access, or similar platforms).
· Ability to maintain professional boundaries, demonstrate cultural humility, and work effectively with individuals from diverse racial, ethnic, cultural, socioeconomic, gender, and identity backgrounds.
· Strong organizational, time management, and follow-through skills, with the ability to prioritize competing demands in a fast-paced residential environment.
· Ability to provide coaching, support, and direction to frontline staff; experience in reflective supervision preferred.
· Computer proficiency in Microsoft Office Suite and the ability to learn new systems and electronic documentation platforms as required.
· Ability to work independently, exercise sound judgment, and consult appropriately with supervisors and team members.
Physical Requirements
· Ability to travel between program sites, attend appointments, and conduct resident meetings both on- and off-site as needed.
· Ability to remain in a stationary position for extended periods and move throughout the facility to interact directly with residents and staff.
· Ability to lift, carry, push, or pull up to 20 pounds occasionally for transporting files, supplies, or program materials.
· Ability to climb stairs, bend, reach, stoop, and perform movements consistent with the needs of a multi-level residential environment.
· Ability to respond to crises, including after-hours and on-call situations, which may require rapid movement, environmental assessment, and communication under pressure.
· Visual and auditory acuity sufficient to observe resident behavior, assess safety risks, and communicate effectively with residents, staff, and external providers.
Health Requirements
To promote a healthy and safe workplace, Hearth strongly encourages all employees to stay up to date with COVID-19 and Influenza (flu) vaccinations. Individuals who choose not to be vaccinated may complete a declination form or request an exemption. Must follow Hearth’s mitigation guidelines in accordance with organizational policy, subject to current state requirements.
Equal Employment Opportunity (EEO) Statement
Hearth is an equal opportunity employer and is committed to creating a diverse and inclusive workplace. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity or expression, national origin, age, disability, veteran status, or any other characteristic protected by applicable law. We strongly encourage applications from individuals of all backgrounds who are passionate about advancing our mission to end elder homelessness.
Americans with Disabilities Act (ADA) Statement
Hearth is committed to providing reasonable accommodations to qualified individuals with disabilities in the application and employment process.
Employees in this role must be able to meet the essential requirements of the position, with or without reasonable accommodation, including standing, walking, bending, and assisting residents as needed.
Pay: From $95,000.00 per year
Benefits:
- 401(k) matching
- Dental insurance
- Disability insurance
- Employee assistance program
- Flexible schedule
- Flexible spending account
- Health insurance
- Life insurance
- Paid sick time
- Paid time off
- Vision insurance
- Wellness program
Work Location: In person
