Overview:
* Work locations include residential and community sites.
* Must be willing and able to travel to member's homes and work remotely occasionally.
* Valid driver's license with no restrictions. Ability to be active and mobile across Massachusetts
* Ability to plan your own day around assessments
* No need to go to an office outside of home assessments
Responsibilities:
* Conducts in-person assessment visits and clinical exams, if appropriate, and relevant screenings within assigned territory as scheduled to capture members' clinical needs and meet regulatory requirements.
* Medication reconciliation, adherence concerns, vital signs, and acute and chronic disease education.
* Complete additional tools or screeners as needed, including relevant behavioral health screeners (PHQ-9, EASI, Audit, DAST).
* Uses clinical judgment to escalate members with urgent needs to the Regional RN Supervisor and/or manager during or immediately following the visit.
* Utilize our electronic health record, scheduling platforms, and claims platforms to collect data, document member interactions, organize information, and communicate with your team, members, and care team.
* Understanding of how to use electronic health record systems and /or care management platforms to ensure accurate documentation.
* Willing and able to pivot to various tasks as needed to support the needs of the department best.
* Adaptable to change and prepared for frequent, fast-paced changes and shifting priorities.
* Ensures immediate referral to time-sensitive services such as behavioral health, long-term services, and support.
* Manages assessment activities through the calendar and tracks the status of completion.
* Participates in assessing and improving quality within the scope of responsibilities and throughout the organization.
* Participates in activities and education to maintain and advance clinical competencies
* Seeks to maintain a constructive work environment and maintains effective communication with other employees and managers.
* Maintains confidentiality of patient and employee information.
* Compliance with the organization's policies and procedures.
* Provide clinical assessments to members via telehealth technologies (video, chat, etc.) when clinically appropriate.
* Use the data collected during the assessment to identify member concerns and unmet needs so that the care team can develop and formalize an individualized care plan.
* Collaborate with care team members to determine whether members need to be placed in a different program (for example, lower or high-intensity programs).
Qualifications:
* Massachusetts RN License
* Associates Degree in Nursing
* 1+ Year of Clinical Experience
* Valid Driver's License
Schedule/Shift :
Monday - Friday 8am-4pm or 9am-5pm