Community Partners Registered Nurse

Community Partners Registered Nurse

Do you enjoy taking a proactive and innovative approach to finding solutions for complex medical and behavior health needs through intensive care coordination and clinical care management? As the Registered Nurse, you will be part of a team that does that!

This is a full-time, non-exempt (35 hour/week) position. We offer a hybrid remote schedule (1 day/week in the office) and the option of a flexible 4-day work week. Our office is located in Malden, MA.

If you want to be part of the progressive approach MassHealth is taking to meet the needs of its participants, by creating a Person-Centered Treatment Plan (PCTP) inclusive of any Long-Term Services and Supports (LTSS) and / or social determinants of health (SDH) needs, then we need you!

Compensation: Starting annual salary is $73,785.71. Enjoy benefits that start as of day 1 of employment and our generous paid time off package.

With a refreshing culture that is supportive, collaborative, and encouraging of diverse perspectives and backgrounds and a satisfying balance between your work and personal life, why not join the Mystic Valley Elder Services' Team!

Working at MVES means:

• A focus on innovation with a team recognized for developing and implementing innovative programs and novel solutions
• Encouragement of your development through opportunities to get involved, use your voice, and gain new knowledge and skills
• Competitive salaries
• Tufts Medical insurance, Delta Dental and VSP Vision insurance effective 1st day of employment
• 403b Retirement Plan with agency contribution after 2 years of employment
• 3 weeks accrued Vacation time
• 3 weeks accrued Sick time
• 13 Paid Holidays
• 30 personal hours

What you'll be Responsible for:

Essential functions of the position are below. Additional duties may be assigned as required.

• Conduct comprehensive assessment of enrollees including the medical, psychiatric and social issues of enrollees served.
• Review/sign off on medical component of comp assessment of Care Team enrollees and of health related/medical Person-Centered Treatment Plan goals of Care Team enrollees, as needed.
• Organize and facilitate the effective functioning of the Interdisciplinary Care Team (ICT), including coordinating meetings, facilitating communication and documentation.
• Monitor the enrollee's health status and needs and provide nursing and medical care coordination as needed.
• Assist team with outreaching and screening of new referrals, providing information and education to enrollees regarding the LTSS CP program and demonstrating value of the program to enrollees, caregivers, PCPs, and other providers.
• Collaborate closely with PCP and other Providers including, but not limited to community resources, and assure appropriate referrals based on level of care needed to optimize outcomes and minimize risk.
• Collaborate with ACO Plan, PCP and other health care Providers regarding changes in services, care transitions, crisis intervention; while focusing on continuity and quality of enrollee care and potential efficiencies and cost-savings.
• Conduct medication reviews for enrollees including adjustment by protocol.
• Follow up after enrollee's ER visits and admission to a planned or unplanned medical or psychiatric inpatient stay, (including hospital, Rehab facility, shelter, substance abuse programs), and collaborate with enrollee, care team staff, ICT and hospital staff to coordinate safe inpatient discharges.
• Perform other duties, as required.

Qualifications:

• Registered Nurse licensed in the Commonwealth of Massachusetts. RN, BSN or MSN.
• Minimum of 5 years clinical and case management experienced preferred.
• Effective skills in managing, teaching, negotiating, and collaborating with multidisciplinary teams and enrollee/family focus.
• Experience working with people with psychiatric disability, co-occurring disorders preferred.
• Strong commitment to the right and ability of people served to live, work, have meaningful relationships and receive the resources and supports needed in their community of choice
• Knowledge of person-centered, strengths-based, recovery-oriented and rehabilitative values, principles, techniques, and modalities
• Knowledge of formal and informal assessment practices
• Knowledge of health promotion and clinical care coordination techniques, and health risks of prevalence with adults with behavior health and/or substance use disorders
• Knowledge of motivational interviewing, stage of change and harm reduction techniques
• Knowledge of trauma-informed and culturally responsive services. Sensitivity to the cultural, religious, ethnic, disability, and gender issues
• Skills and competence to establish supportive trusting relationships with Enrollees and caregivers
• Knowledge of human, legal, civil rights, community, and other resources
• Knowledge of available community health, mental health and SUD services and resources
• Ability to work in a professional and confidential capacity, knowledge of HIPAA requirements.
• Ability to work independently and as member of a multidisciplinary team.
• Excellent verbal and written communication skills, including the ability to write individualized care plans.
• Strong organizational and time management skills. Ability to triage/balance competing priorities
• Ability to problem solve, transition among tasks, and take initiative.
• Ability to make sound decisions and demonstrate strong ethics and professional boundaries.
• Computer skills: Proficient with MS Office Suite, and entering narrative and other data into a database. Working knowledge of Excel. Ability to use the Internet to conduct information searches.
• Preference given to those with lived experience of psychiatric conditions.

Driving Requirements:

• Driving is a requirement for this position using a personal vehicle. You must possess and maintain adequate insurance as well as maintain a safe driving record which is subject to annual checks. A valid driver's license must be presented at the time of employment. Incumbents must be at least 21 years of age, have maintained a valid US driver's license for at least one year, and must be able to pass a driver's screening background check.

Mystic Valley Elder Services is an equal opportunity employer, and all qualified applicants will receive consideration for employment without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.

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