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.

Associate Degree in Nursing required; Bachelor’s in Nursing preferred.
RN license in good standing in the Commonwealth of Massachusetts.
Minimum of 1 year clinical experience (including clinical rotations).
Experience working in HIPAA-compliant or healthcare settings.
Experience with electronic medical records (EMR).
Prior experience in care management or managed care.
Ability to conduct independent assessments and escalate clinical concerns appropriately.
Strong organizational, communication, and interpersonal skills.
Intermediate to advanced proficiency in Microsoft Office and EHR platforms.
Able to work independently in the field and navigate shifting priorities.
Willing to travel throughout Massachusetts with a valid, unrestricted driver’s license.
Comfortable with technology and remote collaboration platforms.
Candidates with bilingual proficiency in English and Spanish are strongly encouraged to apply

Field RN – MDS Assessments

Key skills