The pay range for this position is $78,000 - $86,000/year. The final compensation for RN positions will be determined by assessing each candidate's experience in accordance with established compensation guidelines.

The Registered Nurse: Home Care is responsible for participating in the interdisciplinary approach to case management of elders living in the community. The Registered Nurse: Home Care facilitates the transition of consumers to and from the nursing facility. This includes assessing for, monitoring, and authorizing personal care services as well as determining clinical eligibility for community programs. The Registered Nurse: Home Care develops community care plans for elders in accordance with the guidelines set by the Executive Office of Aging & Independence, MassHealth, and agency standards.

Essential Functions:

• Perform on-site evaluation of consumers in both the community residence and in nursing facilities, including review of medications and a clinical assessment.
• Conduct field visits to assess an older adult's physical, social, emotional, and environmental status to determine their eligibility and needs in their homes.
• Participate on an interdisciplinary team of Registered Nurse, Case Manager and Program Manager; attend appropriate case consultations and conferences.
• Work collaboratively to develop complex care plans and enhanced service plans according to high-risk protocols with the goal to diminish barriers to receiving services.
• Determine clinical eligibility for MassHealth recipients or applicants for nursing home placement, adult day health, home and community-based waiver services, and other community-based programs.
• Assist in the coordination of discharge planning for appropriate elders from the nursing facility setting to the community, including service planning.
• Work with the consumers and involved supports to develop a service plan which addresses the consumer's needs, values and preferences.
• Assess, implement and monitor the appropriateness of Personal Care/Homemaker services.
• Provide education on health and wellness resources to consumers and families.
• Complete necessary electronic documentation determining/supporting the level of care for community services and/or nursing facility placement according to the Executive Office of Aging & Independence and MassHealth regulations.
• Support ASAP nursing team with coverage as needed.
• Perform additional tasks as directed by the Nurse Manager, including piloting, implementing, and evaluating new programs as they are developed.

Additional Functions:

• Attend appropriate agency and community meetings.
• Participate in agency committees as indicated, enhancing the effectiveness and quality of the clinical component of assessed needs.

Qualifications: A valid Massachusetts Registered Nurse license is required. Applicants must have a valid driver's license and reliable transportation. The combination of education level and related experience required is as follows:

• a Bachelor of Science in Nursing or Associate of Science in Nursing degree and at least one (1) year of clinical experience and/or nursing in a community or long-term care setting; or
• a Diploma RN and two (2) additional years of community-based nursing experience or long-term care direct service experience

Must be willing and able to perform community assessments on a regular basis and possess good written, verbal, interpersonal and computer skills and the ability to work in an interdisciplinary team-based environment. Bilingual ability a plus.

Hours: 37.5 per week