Assessment RN

Mass General Brigham•Somerville, MA

1d•Hybrid

About The Position

Mass General Brigham Health Plan seeks an Assessment Registered Nurse (RN) to conduct initial and ongoing comprehensive assessments and evaluations for members, in person, virtually, or by telephone. The RN ensures assessments are accurate and high quality and submits required documentation to MassHealth on time. Using tools such as the Minimum Data Set (MDS), Comprehensive Assessments, and Functional Assessments, the RN gathers relevant information to identify member concerns and unmet needs. The Assessment RN works closely with members’ Interdisciplinary Care Teams and other departments to coordinate timely interventions and support improved outcomes. The role primarily serves members in Massachusetts communities and involves visits to members’ homes, community locations, and residential sites. Caseload and responsibilities may change in response to enrollment trends. This is a full-time hybrid position combining practice-based work, remote work, and in-person home and community visits. The schedule is Monday through Friday, 8:30 a.m. to 5:00 p.m. The role requires local availability, ideally in Eastern Massachusetts, and the ability to travel within the community. The RN has autonomy to schedule work around members’ needs. Remote work requires a stable, quiet, secure, compliant workspace and access to Teams Video using MGB equipment.

Requirements

Bachelor’s degree in Nursing.
Massachusetts Registered Nurse (RN) license.
Valid driver’s license and reliable transportation.
At least 3–5 years of experience in health plan or community case management.
Experience working with individuals with complex medical, behavioral, and social needs.
Strong communication and interpersonal skills for engaging enrollees and interdisciplinary teams.
Critical-thinking and problem-solving skills.
Autonomous decision-making and prudent judgment based on objective information, clinical experience, and the nursing process.
Strong organizational skills, including the ability to manage routine work, triage, and reset priorities.
Ability to build rapport and trust with providers and their staff and promote Population Health initiatives.
Excellent oral, written, and telephonic communication skills.
Competency working with multiple healthcare computer platforms.
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.
Ability to adapt to change and participate in continuous process improvement.
Ability to accommodate a hybrid work model and travel for in-person home and community visits.
Ability to maintain a stable, quiet, secure, compliant remote workstation and access Teams Video using MGB equipment.

Nice To Haves

Master’s degree in Nursing.
Experience with community case management and comprehensive assessment (MDS).
Experience with dual-eligible populations (Medicare and Medicaid).
Bilingual ability in English and Spanish, Portuguese, French, and/or Chinese.
EPIC experience.

Responsibilities

Conduct initial and ongoing comprehensive face-to-face assessments and evaluations for members, with outreach by telephone, electronic communication, or in-person visits according to member preferences and needs.
Travel to enrollees’ homes, community locations, and residential sites to complete assessments.
Independently manage scheduling, including coordinating face-to-face appointments with members.
Collaborate with primary care providers, the interdisciplinary team, and the community care management team to coordinate care.
Complete medication reconciliation.
Provide education on acute and chronic disease management.
Analyze assessment data and share it with the Interdisciplinary Care Team to support development of an effective individualized care plan.
Ensure assessments are accurate, high quality, and documented and submitted to MassHealth in a timely manner.
Adapt to fast-paced changes and shifting priorities.