Registered Nurse

Provide nursing admissions, comprehensive assessments and ongoing clinical oversight for assigned members. Direct assigned LPN clinical work, educate caregivers and coordinate with Case Managers and Operations to maintain safe, compliant and continuous care.

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.

Field-based throughout assigned regions; organizational office in Braintree, MA (office attendance only as needed for training or requested meetings)

• Perform assigned RN admissions, initial and ongoing nursing assessments, semiannual and annual evaluations and other required nursing visits within established time frames.
• Review available clinical history, primary care provider summaries, diagnoses, medications, functional needs and identified risks to establish an accurate clinical picture.
• Develop, implement, review and update nursing components of the plan of care in collaboration with the member, caregiver, Case Manager and healthcare team.
• Assess changes in condition, reconcile medication information within RN scope and coordinate timely follow-up with the primary care provider and appropriate clinical resources.
• Provide a complete admission handoff to the Case Manager and Regional Manager so ongoing visit cadence and support can begin without gaps.

• Provide and document caregiver orientation, skills education, reinforcement and competency follow-up as required by the member’s plan and program standards.
• Assess caregiver understanding, performance and support needs; address identified care or safety concerns through education and escalation.
• Review assigned caregiver logs at least every 30 days, including between nursing visits; evaluate discrepancies against clinical assessments and the plan of care.
• Provide clinical direction, supervision and review of assigned LPN activities, including follow-up on escalated concerns and documentation of required oversight.

• Communicate significant health changes, urgent concerns and potential service interruptions promptly to appropriate clinical and operational leaders.
• Coordinate with Case Managers, caregivers, providers and regional teams regarding hospitalizations, transitions, changing needs and discharge planning.
• Complete required nursing progress notes, reports and semiannual health-status communications to the primary care provider accurately and on time.

• 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 with Scheduling to coordinate nursing admissions, assessments, follow-up visits and caregiver availability; communicate clinical priorities and changes while supporting efficient field routing.
• Assess and document clinical and safety factors affecting the suitability of the home setting, including member needs, caregiver capabilities, emergency preparedness and environmental risks; coordinate qualified-setting concerns with the Case Manager and regional leadership.
• Provide clinical input and practical support to case management, including evaluation of changes in member condition, caregiver training needs, service barriers and appropriate care-plan revisions.
• Work with the Case Manager and Scheduling to address missed visits, caregiver transitions and changes in home readiness before they disrupt safe service delivery.

• 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.