Field RN – MDS Assessments

Responsibilities

• Conduct in-person assessment visits and clinical exams, including relevant screenings within assigned territory.
• Perform medication coaching and reconciliation, identify adherence concerns, and provide patient education on acute and chronic diseases.
• Complete screeners such as PHQ-9, EASI, Audit, DAST, and Minimum Data Set
  - Home Care as needed.
• Prioritize and elevate members with urgent needs to RN Supervisor or manager promptly.
• Use electronic health record and claims systems to document and track member interactions and care needs.
• Ensure timely referrals to behavioral health and long-term services as appropriate.
• Manage scheduling and tracking of assessments to ensure timely completion.
• Participate in quality improvement activities and maintain clinical competencies.
• Maintain effective communication and a constructive work environment with team members.
• Comply with organizational policies, privacy regulations, and documentation standards.
• Provide clinical assessments via telehealth when appropriate.
• Continuously assess member’s engagement within the designated care pathway, and determine program fit.
• Collaborate with care and decision makers to ensure program alignment.
• Other duties as assigned.

• Associate Degree in Nursing required;
  Bachelor’s in Nursing preferred.
• RN license in good standing in the Commonwealth of Massachusetts.
• Minimum of 1 year clinical experience (including clinical rotations).
• Experience working in HIPAA‑compliant or healthcare settings.
• Experience with electronic medical records (EMR).
• Prior experience in care management or managed care.
• Ability to conduct independent assessments and elevate clinical concerns appropriately.
• Strong organizational, communication, and interpersonal skills.
• Intermediate to advanced proficiency in Microsoft Office and EHR platforms.
• Able to work independently in the field and navigate shifting priorities.
• Willing to travel throughout Massachusetts with a valid, unrestricted driver’s license.
• Comfortable with technology and remote collaboration platforms.
• Candidates with bilingual proficiency in English and Spanish are strongly encouraged to apply.