Field RN - MDS Assessements

Activate Care•Worcester, MA

48d•Hybrid

About The Position

Activate Care is dedicated to enhancing health equity and improving health outcomes nationwide. Our platform, Care Link, facilitates care coordination for populations facing health-related social needs (HRSN) by connecting healthcare and community organizations. The Path Assist program, a tech-enabled Community Health Worker initiative, addresses HRSN through structured, evidence-based interventions. Our core objective is to meet individuals' unmet HRSNs, boost health confidence and self-efficacy, and reduce unnecessary healthcare expenditures.

Requirements

Associate Degree in Nursing required
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.

Nice To Haves

Bachelor’s in Nursing preferred
Candidates with bilingual proficiency in English and Spanish are strongly encouraged to apply

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.