Assessment RN

Site: Mass General Brigham Health Plan Holding Company, Inc. 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. Job Summary Given equity, this position will pay somewhere between $90,000 to $110,000 annually. Mass General Brigham Health Plan is an exciting place to be within the healthcare industry. As a member of Mass General Brigham, we are at the forefront of transformation with one of the world’s leading integrated healthcare systems. Together, we are providing our members with innovative solutions centered on their health needs to expand access to seamless and affordable care and coverage. Our work centers on creating an exceptional member experience – a commitment that starts with our employees. Working with some of the most accomplished professionals in healthcare today, our employees have opportunities to learn and contribute expertise within a welcoming and supportive environment that embraces their unique and varied backgrounds, experiences, and skills. We are pleased to offer competitive salaries and a benefits package with flexible work options, career growth opportunities, and much more. Mass General Brigham Health Plan seeks an 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 member concerns and unmet needs. The Assessment RN collaborates closely with the member's Interdisciplinary Care Team and other departments to facilitate timely interventions aimed at improving outcomes for Mass General Brigham members. The population will primarily include members residing in Essex, Middlesex, Suffolk, Norfolk, Plymouth, Bristol, Dukes, and Nantucket counties. This position's responsibilities and caseload may be adjusted based on member enrollment trends. Essential Functions • Conducts initial and ongoing comprehensive face-to-face assessments and evaluations for members. 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. Qualifications Education Bachelor's Degree Nursing required or Master's Degree Nursing preferred Licenses and Credentials Massachusetts (MA) Registered Nurse (RN) license Valid Driver's License and reliable transportation Experience At least 3-5 years of 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  Knowledge, Skills, and Abilities 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 healthcare 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  Additional Job Details (if applicable) Working Model Required This is a full-time position with a schedule of Monday through Friday, 8:30 AM-5:00 PM EDT This is a hybrid schedule, which includes practice-based work, remote work, and in-person home and community visits (these days will vary weekly, and these visits may increase as member trends evolve) Must be local, ideally in Eastern, MA, with the ability to travel to the community. This