Registered Nurse (RN) - Hybrid (Boston and Surrounding Areas)

Job title: Registered Nurse (RN) - Hybrid (Boston and Surrounding Areas)

About the Role Care Delivery RN collaborates with an interdisciplinary team to provide primary care, in-home specialty care, and care coordination to a panel of high-risk, complex patients, including individuals with medical, behavioral, and social complexities that require intensive care coordination and care delivery.

What You'll Do

• Delivers care to complex patients, providing care management and care coordination support, and collaborating with external providers to deliver comprehensive care.
• Conducts basic health assessments and provides direct and indirect nursing care within RN scope of practice and with signed provider's order as necessary.
• Escalates all pertinent clinical findings to assigned APC within specified timeframes.
• Conducts follow-up telephone calls with patients to ensure satisfaction.
• Assesses quality gap reports at each face-to-face visit; collaborates with care team and PCP to close identified gaps.
• Ensures timely medical post-hospital discharge with focus on hospitalization and utilization reduction.
• Documents all visits with clear, comprehensive, and concise charting while adhering to policies and procedures.
• Communicates clear loop closure to the interdisciplinary care team and plans for member-centric follow-ups as indicated.
• Identifies and initializes a plan to resolve areas of opportunity to meet KPIs.
• Proactively and collaboratively work with the patient's PCP and other external providers on key care management/care coordination decisions to ensure a cohesive medical treatment plan is delivered.
• Participates in interprofessional Care Team meetings, clinical committees, completes ongoing education and training, and provides consultation and support to other members of Care Team.
• Assists management with developing, refining and enhancing clinical programs, initiatives, processes, policies, workflows, and projects.
• Completes Health Plan assessments at scheduled and timely intervals and off-cycle as needed.
• Routinely and accurately completes the member-centric Care Plan and updates to PCP, Providers, and HP as required.
• Regular travel to conduct member, provider and community-based visits as needed to ensure effective administration of the program.
• Supports the procurement of DME, transportation, LTSS services and supports, and community supports as approved.
• Supports the procurement of network providers and assists in closing any gaps in service or care.
• Performs any other job related duties as requested.

What We're Looking For

• Education and Experience: Associate degree in nursing required; Bachelor’s degree in nursing preferred.
• Experience: Five (5) years as RN in a high-touch clinical environment or home care required; Two (2) years caring for patients/members with complex medical, behavioral health, and social needs required; Three (3) years experience in outreach or community care for patients with complex needs preferred.
• Licensure and Certifications: Current unrestricted Massachusetts RN license; Basic Life Support certification; valid driver’s license, vehicle and verifiable insurance.
• Skills: Experience with EMR strongly preferred; disability issues and Medicaid/Medicare programming/insurance products (ACO, MCO, PACE, SCO) preferred.
• Competencies and Abilities: Excellent written and verbal communication; ability to work with diverse groups; strong organizational, time management and problem-solving skills; ability to use EMR and telehealth technologies; bilingual or multilingual preferred.
• Travel: Ability to travel as required.

Nice to Have

• Bilingual or multilingual (preferred).
• Additional preferred experience with Medicaid/Medicare programs and telehealth tools.