Job Description

Overview

Mass General Brigham Health Plan is hiring two RNs: Assessment Registered Nurse (RN) who will perform initial and ongoing face-to-face, virtual, or telephonic comprehensive assessments and evaluations. The Assessment RN ensures the accuracy and quality of all assessments and the timely submission of documentation to MassHealth. The RN completes timely, accurate, and high-quality assessments using tools such as the Minimum Data Set (MDS), Comprehensive assessments, and Functional Assessments to identify enrollees concerns and unmet needs. The Assessment RN collaborates with the enrollee's Interdisciplinary Care Team and other departments to facilitate timely interventions aimed at improving outcomes for Mass General Brigham enrollees.

Responsibilities

• Conducts initial and ongoing comprehensive face-to-face assessments and evaluations for Mass General Brigham enrollees. Outreach may occur via telephone, electronic communication, or in-person visits, depending on the enrollees preferences and current needs.
• Travels to enrollees homes, community locations, and residential sites to complete comprehensive assessments.
• Independently manages 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.
• Delivers 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 adaptability and readiness to navigate frequent, fast-paced changes and shifting priorities.

Qualifications

• Registered Nurse [MA- State License] required, active RN license in good standing with continuing education requirements met.
• Associates Degree in Nursing required.
• Bachelors Degree in Nursing preferred.
• Valid Drivers License and reliable transportation.
• Minimum of 35 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 with multiple health care computer platforms; EPIC experience is a plus.
• Experience working with individuals with complex medical, behavioral, and social needs.
• Strong communication and interpersonal skills to engage with enrollees and interdisciplinary teams.
• Critical thinking and problem-solving skills; demonstrates autonomy in decision making.
• Uses prudent judgment based on objective information, clinical experience, and nursing process.
• Strong organizational skills with the ability to manage routine work, triage, and reset priorities as needed.
• Interpersonal skills to work effectively with providers and their staff to develop rapport, build trust, and promote Population Health initiatives; excellent oral, written, and telephonic skills.
• Ability to work effectively in a complex, fast-paced medical environment and across multiple practice locations.
• Ability to work independently while contributing to a collaborative team environment.
• Knowledge of healthcare and community services to assist enrollees effectively.
• Comfort with change and the ability to adapt and pivot as part of continuous process improvement activities.

Working Model Required

• MondayFriday, Eastern Business Hours required (830a5pm ET).
• Onsite practice-based, remote work, and enrollee in-person home and community visits.
• Weekly multiple days in the field; schedule will vary.
• Reliable transportation and valid drivers license required.
• Must be local, ideally in Eastern, MA; community-capable with autonomy to build own schedule to accommodate member needs, with flexibility for training, field work, and business needs. In-person, telephonic, or virtual assessments possible.
• Field work may increase as the program launches.
• Remote working days require a stable, quiet, secure, compliant working station using MGB-provided equipment and Teams video access.

Our goal is to geographically align employees; this may vary based on residence, business needs, member enrollment, and team staffing.

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

Location and Population

The population will primarily include enrollees residing in Essex, Middlesex, Suffolk, Norfolk, Plymouth, Bristol, Dukes, and Nantucket counties. Responsibilities and caseloads may be adjusted based on enrollee enrollment trends.

Mass General Brigham Health Plan Holding Company, Inc. is an Equal Opportunity Employer. By embracing diverse skills, perspectives and ideas, we choose to lead. 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.

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