Brigham and Women's Hospital-posted about 2 months ago
Full-time • Mid Level
Hybrid • Braintree, MA
5,001-10,000 employees
Hospitals

Mass General Brigham relies on a wide range of professionals, including doctors, nurses, business people, tech experts, researchers, and systems analysts to advance our mission. As a not-for-profit, we support patient care, research, teaching, and community service, striving to provide exceptional care. We believe that high-performing teams drive groundbreaking medical discoveries and invite all applicants to join us and experience what it means to be part of Mass General Brigham. Coordinated Whole HealthCare Duals team is hiring two Assessment RNs for our growing program! The population will primarily include enrollees residing in Essex, Middlesex, Suffolk, Norfolk, Plymouth, Bristol, Dukes, and Nantucket counties. This position's responsibilities and caseload may be adjusted based on enrollee enrollment trends. Mass General Brigham Health Plan is hiring two RNs: Assessment Registered Nurse (RN) to perform initial and ongoing face-to-face, virtual, or telephonic comprehensive assessments and evaluations. The Assessment RN is responsible for ensuring the accuracy and quality of all assessments, as well as the timely submission of documentation to MassHealth. The Assessment RN completes timely, accurate, and high-quality assessments. They utilize tools such as the Minimum Data Set (MDS), Comprehensive, and Functional Assessments to gather relevant data, enabling them to identify enrollee's concerns and unmet needs. The Assessment RN collaborates closely with the enrollee's Interdisciplinary Care Team and other departments to facilitate timely interventions aimed at improving outcomes for Mass General Brigham enrollees.

  • 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 enrollee's preferences and current needs.
  • Travels to enrollees' homes, community locations, and residential sites to complete comprehensive assessments.
  • Ability to independently manage 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
  • Provides 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 the adaptability and readiness to navigate frequent, fast-paced changes and shifting priorities.
  • Registered Nurse [MA- State License] required, Active RN license, in good standing with meeting all continued education requirements
  • Associate's Degree, Nursing, Required
  • Valid Driver's License and reliable transportation
  • Minimum of 3-5 years' experience in health plan or community case management
  • Competency in working with multiple health care computer platforms, nice to have EPIC experience
  • Experience working with individuals with complex medical, behavioral, and social needs
  • Strong communication and interpersonal skills to effectively engage with enrollees and interdisciplinary teams
  • Critical thinking and problem-solving skills. Demonstrates autonomy in decision making
  • Uses prudent judgment based upon objective information, clinical experience, and nursing process.
  • Strong organizational skills with an ability to manage routine work, triage and reset priorities as needed
  • Interpersonal skills and ability to work effectively with providers and their staff to develop rapport, build trust, and promote Population Health initiatives. Excellent oral, written, and telephonic skills and abilities
  • Competency in working with multiple health care computer platforms
  • Ability to work effectively in a complex fast paced medical environment and multiple practice locations
  • Ability to work independently while contributing to a collaborative team environment
  • Knowledge of healthcare and community services to assist enrollees effectively
  • Must be comfortable with change, have the ability to adapt and pivot as part of continuous process improvement activities
  • M-F Eastern Business Hours required 830a-5pm ET
  • Onsite Practice-based, remote work and enrollee in-person home and community visits
  • Weekly multiple days in field needed, will vary
  • Reliable transportation and valid driver's license required
  • Must be local, ideally in Eastern, MA. Community capable with autonomy to build own schedule to accommodate member's needs. With flexibility required based on member needs
  • Must be flexible for training, field work and business needs, this can very per week in person, as well as telephonic or virtual assessments are possible.
  • Field work may be increased as the program launches
  • Remote working days require stable, quiet, secure, compliant working station using MGB provided equipment and Teams Video access
  • Employee must accommodate the hybrid work model, including practice-based, remote work and enrollee in-person home and community visits.
  • Bachelor's Degree, Nursing preferred
  • 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
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