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.

The responsibilities listed below represent the essential functions of the position and are not intended to be an exhaustive list of all duties, responsibilities, or qualifications associated with the role. Location: Field-based throughout assigned regions; organizational office in Braintree, MA (office attendance only as needed for training or requested meetings)

Essential Duties and Responsibilities

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. The Braintree, Massachusetts office is the organizational base; office attendance is limited to required training, meetings or other specifically requested activities.
• 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.
• Regular business hours are generally Monday through Friday; however, schedule flexibility may be required to support member needs, operational priorities, training requirements or business necessity.

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.

Performance Expectations

• Required case management visits and assessment milestones completed on time.
• Accuracy, completeness and timeliness of case management notes, plans and other required records.
• Caregiver logs reviewed within every required 30-day cycle.
• Timely completion of referrals, member/caregiver follow-up and transition actions.
• At-risk case interventions documented, escalated and followed through to resolution.
• Quality and timeliness of case insights, plan-of-care contributions and escalations to the Regional Manager and Regional Director.
• Efficient field-route planning, accurate mileage documentation and on-time expense report submission.
• Effective collaboration with Scheduling, timely resolution of home-readiness concerns and documented case management support within the role’s scope.

Physical and Environmental Demands

This is a field-based position involving regular travel between member homes and community settings, variable home environments, standing, walking, sitting, computer and mobile-device use, and direct member and caregiver interactions. The organizational office is in Braintree, Massachusetts; office attendance is only as needed for required training or specifically requested meetings. Field routes should be organized efficiently, with accurate mileage reporting in accordance with company policy. Essential duties are performed with reasonable accommodation where applicable.

Additional Expectations

Maintain confidentiality, follow organizational policies and applicable program requirements, participate in required training, and perform other related duties consistent with the position and professional scope as assigned. Vitra Health is an equal opportunity employer.

Perks & Benefits

• Employer-sponsored health insurance.
• Dental and vision insurance.
• Supplemental insurance options.
• 401(k) retirement plan.
• Paid time off and company holidays.
• Wellness benefits and tuition reimbursement, subject to plan terms and company policy.
• Professional and collaborative work environment focused on quality care, operational excellence, and continuous improvement.

Equal Employment Opportunity

Vitra Health is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, age, disability, veteran status, genetic information, sexual orientation, gender identity, or any other protected status under applicable law.