Assessment RN

Mass General Brigham Health Plan
remote work
United States, Massachusetts, Somerville
399 Revolution Drive (Show on map)
Oct 30, 2025
The Opportunity Mass General Brigham Health Plan is hiring two RNs: 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 enrollees' concerns and unmet needs. The Assessment RN collaborates closely with the enrollee's Interdisciplinary Care Team and other departments to facilitate timely interventions aimed at improving outcomes for members. 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. MA Registered Nurse required Associate's Degree, Nursing, required; Bachelor's Degree,Nursing preferred Valid Driver's License and reliable transportation Minimum of 3-5 years' 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 Skills for Success 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 health care 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 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 the program launches) Must be local, ideally in Eastern, MA, with the ability to travel to the community. This role offers autonomy to build own schedule to accommodate members' needs. Remote working days require a stable, quiet, secure, compliant working station and access to Teams Video via MGB equipment Our goal will be to geographically align employees; this depends on residence and can vary based on business needs, member enrollment, and team staffing. Employees must accommodate the hybrid work model, including practice-based work, remote work, and in-person home and community visits with members. The member population will reside primarily in Essex, Middlesex, Suffolk, Norfolk, Plymouth, Bristol, Dukes, and Nantucket counties. The responsibilities and caseload may be adjusted based on enrollment trends. Mass General Brigham Health Plan Holding Company, Inc. is an Equal Opportunity Employer. By embracing diverse skills, perspectives and ideas, we choose to lead. All qualified applicants will receive consideration for employment without regard to race, color, religious creed, national origin, sex, age, gender identity, disability, sexual orientation, military service, genetic information, and/or other status protected under law. We will ensure that all individuals with a disability are provided a reasonable accommodation to participate in the job application or interview process, to perform essential job functions, and to receive other benefits and privileges of employment.