State Home Care Community Health Nurse

Job Description

Job Description

Description:

JOB TITLE: Community Health Nurse / State Home Care
REPORTS TO: Nurse Manager
DEPARTMENT: Home Care
FLSA STATUS: ? Non-Exempt | ? Non-Union

POSITION SUMMARY

The Community Health Nurse plays a vital role on the Home and Community-Based Services (HCBS) team, helping older adults and adults with disabilities remain safely and independently in the setting of their choice. This position combines clinical expertise, autonomy, advocacy, and community-based care coordination to assess eligibility for home care and MassHealth-funded services while supporting high-quality, person-centered outcomes.

As part of the Clinical Assessment and Eligibility (CAE) team, the nurse conducts comprehensive in-home assessments, evaluates clinical documentation, develops individualized care recommendations, and collaborates closely with consumers, families, providers, hospitals, nursing facilities, and interdisciplinary teams. The role also serves as a trusted clinical resource and educator for staff and community partners on aging-related health needs, chronic conditions, and community-based supports.

This is an excellent opportunity for nurses seeking meaningful, relationship-centered work outside of traditional bedside care. Unlike many hospital or facility-based nursing roles, this position offers greater flexibility, autonomy, work-life balance, and the opportunity to build long-term impact within the community.

Why Join SCES?

At Somerville-Cambridge Elder Services (SCES), we are committed to helping older adults and adults with disabilities live with dignity, independence, and connection in the setting of their choosing. Our work is mission-driven, person-centered, and grounded in compassion, equity, and community.

Joining SCES means becoming part of a collaborative, innovative organization where your expertise directly improves lives every day. You will work alongside dedicated professionals who are passionate about strengthening community-based care, supporting caregivers, and helping individuals age safely and successfully in their homes and communities.

SCES also prioritizes employee wellbeing and sustainability. We recognize that supporting our staff is essential to supporting our community. Employees benefit from:

• Hybrid work environment
• 35-hour work week
• Competitive compensation
• Mission-driven culture
• Supportive leadership and interdisciplinary collaboration
• Opportunities for professional growth and community impact
• Greater schedule flexibility and autonomy than many traditional nursing roles

If you are looking for a career that combines clinical expertise, purpose, flexibility, and meaningful human connection, we encourage you to join our team.

KEY RESPONSIBILITIESClinical Assessment & Care Planning

• Conduct comprehensive in-home clinical, functional, and psychosocial assessments for individuals seeking home care and MassHealth-funded services.
• Develop individualized, goal-oriented care plans that support safety, independence, and quality of life.
• Reassess and revise care plans based on changes in health status, functional needs, or social circumstances.
• Conduct in-person Clinical Assessment and Eligibility (CAE) screenings in accordance with MassHealth and EOEA regulations.
• Complete Clinical Decision Support (CDS) determinations and required follow-up activities within established timeframes.

Care Coordination & Collaboration

• Respond promptly to referrals from case managers, healthcare providers, families, and community agencies.
• Collaborate with interdisciplinary teams to support coordinated, person-centered care planning.
• Participate in Interdisciplinary Conferences (IDCs) and provide clinical insight into service planning and risk management.
• Partner with nursing facilities, discharge planners, and interdisciplinary discharge planning teams (IDPTs) to support safe transitions to community living.
• Participate in Community Transitions Liaison Program (CTLP) meetings to identify and support eligible nursing facility residents.

Education, Advocacy & Community Engagement

• Serve as a clinical resource and educator to staff, consumers, families, and community providers regarding aging-related health conditions, available services, and community supports.
• Advocate for consumers and families to ensure access to appropriate services and resources.
• Provide in-service trainings and consultation on health-related topics and best practices in community-based care.

Documentation, Compliance & Quality

• Maintain accurate, timely, and confidential documentation in compliance with agency, EOEA, DMA, and MassHealth requirements.
• Complete assessment documentation, progress notes, care plans, and case records according to professional and regulatory standards.
• Participate in quality improvement initiatives and program evaluation activities.
• Contribute data and reporting information for program metrics and statistical reporting.
• Ensure HIPAA compliance and adherence to agency policies and professional standards.

Additional Responsibilities

• Participate in supervision, department meetings, interdisciplinary team meetings, and required agency trainings.
• Support interpretation and translation services when bilingual skills are available.
• Perform other duties as assigned.

PROFESSIONAL COMPETENCIESRelationship -Centered Care

Demonstrates empathy, professionalism, and cultural humility while building trusting relationships with consumers, caregivers, providers, and community partners.

Collaboration & Communication

Communicates clearly, professionally, and effectively across diverse audiences and disciplines. Works collaboratively within interdisciplinary teams and demonstrates strong follow-through and responsiveness.

Clinical Judgment & Critical Thinking

Applies strong assessment, analytical, and problem-solving skills to evaluate complex situations, identify risks, and develop appropriate recommendations and solutions.

Organization & Adaptability

Effectively manages competing priorities, maintains attention to detail, and adapts to changing needs in a fast-paced community healthcare environment.

Accountability & Professionalism

Demonstrates integrity, reliability, sound judgment, and commitment to SCES’ mission, values, and inclusive workplace culture.

QUALIFICATIONS

• Graduate of an accredited School of Nursing required; BSN preferred.
• Current Registered Nurse (RN) license in the Commonwealth of Massachusetts required.
• Minimum of one year of clinical nursing experience required.
• Community health, home care, geriatrics, care management, or behavioral health experience strongly preferred.
• Experience working with older adults and/or individuals with complex medical or psychosocial needs preferred.
• Ability to work both independently and collaboratively with interdisciplinary teams and community partners.
• Strong assessment, communication, organizational, and time management skills.
• Proficiency with Microsoft 365 applications including Word, Excel, Outlook, SharePoint, and Adobe Acrobat; experience with WellSky a plus.
• Ability to travel to consumer homes and nursing facilities via car or public transportation.
• Valid Massachusetts driver’s license strongly preferred.
• Must be accessible by phone during standard business hours.
• Must meet CORI/SORI and public health screening requirements.

COMPENSATION & BENEFITS

Salary Range: $90,000 – $112,000 annually

SCES offers a competitive and comprehensive benefits package, including health and dental insurance, paid time off, retirement benefits, professional development opportunities, and a strong commitment to employee wellbeing and work-life balance.

PHYSICAL & WORK ENVIRONMENTPhysical Environment

Work is performed in both office and community settings, including consumer homes and nursing facilities.

Physical Requirements

• Frequent sitting, standing, walking, bending, reaching, and stooping
• Ability to lift, push, pull, or carry up to 20 pounds
• Regular computer and documentation work

Work Conditions

• Occasional exposure to stressful or fast-paced situations requiring prioritization and responsiveness
• Local travel required throughout the service area

Employee Name & Signature: ____________________________________ Date: ___________________

Supervisor Name & Signature: __________________________________ Date: __________________

Requirements: