Field (MDS) Registered Nurse (NO CASE MANAGEMENT)

Job Title

Community-Focused Registered Nurse (RN)

Job Description

At Activate Care, we're on a mission to improve health equity and drive improved health outcomes across the country. Our Community Care Record platform, Care Link, enables healthcare and community organizations to coordinate care for populations challenged with health-related social needs (HRSN). Path Assist is our tech-enabled Community Health Worker program for addressing HRSN utilizing an evidence-based, structured intervention. Our goal is simple: address individuals' unmet HRSNs, increase health confidence, improve self-efficacy, and reduce inappropriate healthcare spend.

Role Overview

This community-focused, Registered Nurse (RN) will travel to members' homes across Massachusetts to complete in-person health assessments for a managed care health plan's dually eligible members. The role specializes in conducting timely, accurate assessments and documenting findings, then handing off to the health plan's care management team. This is assessment and documentation work, not ongoing care management.

Responsibilities

• Engage with members in their homes and other community settings to complete assessments, with mindfulness of the cultural and linguistic needs of each member.
• Perform required assessments on a timely basis as assigned under the contract, including Uniform Core Assessments (UCA), Functional Assessments (FA), and Comprehensive Assessments, evaluating each member's physical, cognitive, and functional status.
• Document assessments in the health plan's care management platform (GuidingCare) following the provided workflows and resource guides.
• Send a SOAP note to the assigned health plan Care Manager upon assessment completion.
• Submit accurate, complete documentation within 48 hours of each assessment and maintain a high completeness and quality standard as measured through the health plan's review and audit.
• Complete required training and ongoing training to maintain system access.
• Routinely travel to members' homes and, or community settings to conduct assessments.
• Report abuse, neglect, or exploitation of older adults and adults with disabilities as a mandated reporter, as required by state law.
• Follow field-safety practices for independent in-home visits and escalate clinical or safety concerns appropriately.
• Adhere to all applicable regulatory, privacy (HIPAA), NCQA, and care management standards
• Maintain licensure and or certifications
• Other duties as assigned.