Job Description

Assessment Registered Nurse (RN)

Coordinated Whole HealthCare Duals team is hiring two Assessment RNs for our growing program! The member population will include in Essex, Middlesex, Suffolk, Norfolk, Plymouth, Bristol, Dukes, and Nantucket counties. This position's responsibilities and caseload may be adjusted based on enrollment trends.

Job Summary

Mass General Brigham Health Plan is an Assessment Registered Nurse (RN) to perform initial and ongoing face-to-face, virtual, or telephonic comprehensive assessments and evaluations. The Assessment RN is responsible for ensuring the accuracy and quality of all assessments, as well as the timely submission of documentation to MassHealth. The Assessment RN completes timely, accurate, and high-quality assessments. They utilize tools such as the Minimum Data Set (MDS), Comprehensive, and Functional Assessments to gather relevant data, enabling them to identify enrollees' concerns and unmet needs. The Assessment RN collaborates closely with the enrollee's Interdisciplinary Care Team and other departments to facilitate timely interventions aimed at improving outcomes for members.

Essential Functions

• Conducts initial and ongoing comprehensive face-to-face assessments and evaluations for members. Outreach may occur via telephone, electronic communication, or in-person visits, depending on the enrollee's preferences and current needs.
• Travels to enrollees' homes, community locations, and residential sites to complete comprehensive assessments.
• Ability to independently manage scheduling, including coordinating face-to-face appointments with members as needed.
• Collaborates closely with primary care providers, the interdisciplinary team, and the community care management team to ensure coordinated care.
• Completes medication reconciliation
• Provides acute and chronic disease management education
• Provides analyzed assessment data to the Interdisciplinary Care Team (ICT) to support the development of a more effective individualized care plan (ICP) for the enrollee.
• Demonstrates the adaptability and readiness to navigate frequent, fast-paced changes and shifting priorities.

Qualifications

• MA Registered Nurse required
• Associate's Degree, Nursing, required; Bachelor's Degree, Nursing preferred
• Valid Driver's License and reliable transportation
• Minimum of 3-5 years' experience in health plan or community case management
• Experience with community case management and comprehensive assessment (MDS) Preferred
• Experience with Dual Eligible Populations (Medicare and Medicaid) preferred
• Bilingual candidate preferred, English and Spanish, Portuguese, French, and/or Chinese

Skills for Success

• Competency in working with multiple health care computer platforms, nice to have EPIC experience
• Experience working with individuals with complex medical, behavioral, and social needs
• Strong communication and interpersonal skills to effectively engage with enrollees and interdisciplinary teams
• Critical thinking and problem-solving skills. Demonstrates autonomy in decision making
• Uses prudent judgment based upon objective information, clinical experience, and nursing process.
• Strong organizational skills with an ability to manage routine work, triage and reset priorities as needed
• Interpersonal skills and ability to work effectively with providers and their staff to develop rapport, build trust, and promote Population Health initiatives. Excellent oral, written, and telephonic skills and abilities
• Competency in working with multiple health care computer platforms
• Ability to work effectively in a complex fast paced medical environment and multiple practice locations
• Ability to work independently while contributing to a collaborative team environment
• Knowledge of healthcare and community services to assist enrollees effectively
• Must be comfortable with change, have the ability to adapt and pivot as part of continuous process improvement activities

Working Model Required

• This is a full-time position with a schedule of Monday through Friday, 8:30 AM-5:00 PM EDT
• This is a hybrid schedule, which includes practice-based work, remote work, and in-person home and community visits (these days will vary weekly, and these visits may increase as the program launches)
• Must be local, ideally in Eastern, MA, with the ability to travel to the community.
• This role offers autonomy to build own schedule to accommodate members' needs.
• Remote working days require a stable, quiet, secure, compliant working station and access to Teams Video via MGB equipment

Our goal will be to geographically align employees; this depends on residence and can vary based on business needs, member enrollment, and team staffing.

Employees must accommodate the hybrid work model, including practice-based work, remote work, and in-person home and community visits with members.

The member population will reside primarily in Norfolk, Plymouth, Bristol, Dukes, and Nantucket counties. The responsibilities and caseload may be adjusted based on enrollment trends.

Remote Type

Hybrid

Work Location

399 Revolution Drive

Scheduled Weekly Hours

40

Employee Type

Regular

Work Shift

Day (United States of America)

Pay Range

$58,656.00 - $142,448.80/Annual

Grade

98TEMP

At Mass General Brigham, we believe in recognizing and rewarding the unique value each team member brings to our organization. Our approach to determining base pay is comprehensive, and any offer extended will take into account your skills, relevant experience if applicable, education, certifications and other essential factors. The base pay information provided offers an estimate based on the minimum job qualifications; however, it does not encompass all elements contributing to your total compensation package. In addition to competitive base pay, we offer comprehensive benefits, career advancement opportunities, differentials, premiums and bonuses as applicable and recognition programs designed to celebrate your contributions and support your professional growth. We invite you to apply, and our Talent Acquisition team will provide an overview of your potential compensation and benefits package.

EEO Statement:

Mass General Brigham Health Plan Holding Company, Inc. is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religious creed, national origin, sex, age, gender identity, disability, sexual orientation, military service, genetic information, and/or other status protected under law. We will ensure that all individuals with a disability are provided a reasonable accommodation to participate in the job application or interview process, to perform essential job functions, and to receive other benefits and privileges of employment. To ensure reasonable accommodation for individuals protected by Section 503 of the Rehabilitation Act of 1973, the Vietnam Veteran's Readjustment Act of 1974, and Title I of the Americans with Disabilities Act of 1990, applicants who require accommodation in the job application process may contact Human Resources at (857)-282-7642.

Mass General Brigham Competency Framework

At Mass General Brigham, our competency framework defines what effective leadership "looks like" by specifying which behaviors are most critical for successful performance at each job level. The framework is comprised of ten competencies (half People-Focused, half Performance-Focused) and are defined by observable and measurable skills and behaviors that contribute to workplace effectiveness and career success. These competencies are used to evaluate performance, make hiring decisions, identify development needs, mobilize employees across our system, and establish a strong talent pipeline.

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