Registered Nurse, MDS Assessments (Full & Part-Time)

Job Title

This is a FULL TIME, HYBRID role where applicants should reside within 30 minutes from Boston, MA to be strongly considered for this position.

About Activate Care

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

The RN conducts high-quality, timely in-person clinical assessments in members' homes and in community settings across Massachusetts. Using clinical judgement, the position will complete intake assessments, notating SDOH needs, while maintaining compliance with MassHealth and Medicaid, SNP member guidelines. This role identifies unmet medical, behavioral, and social needs and collaborates with internal care teams to drive appropriate interventions. The position requires strong clinical judgment, field-based experience, and comfort with electronic health record systems.

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, and DAST, and Minimum Data Set- Home Care as needed.
• Prioritize and escalate 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, decision makers to ensure program alignment.
• Other duties as assigned.