Community RN - Health Home Management

Community Healthlink - Worcester, MA2.9

Come join a friendly and diverse clinical team that provides quality care! Community Healthlink (CHL) is looking for a full-time (37.5 hrs/wk) Community RN in Central Massachusetts.

CHL’s Health Home Management (HHM) department provides care management to CHL clients who are also enrolled in Commonwealth Care Alliance’s OneCare program. We help coordinate these individuals’ primary and behavioral health care to ensure they receive high-quality, integrated care. We work with our clients and their health care providers as a team to create an individualized personal care plan for each client, and then follow-up with the clients and providers regularly to ensure the care plan is meeting the client’s health needs. CHL’s Health Home Management department offers staff an opportunity to learn about a variety of topics in health care, including insurance authorizations, long-term home services, primary care, behavioral health, addiction treatment, and hospital care.

The Registered Nurse (RN) case manager is responsible for all initial and annual Minimum Data Sheet (MDS) assessments, care plans, eClinical Works (ECW) documentation and meeting time sensitive submission processes. The RN needs to be a collaborative team player providing support for the case management teams and will have a small case load of One Care HHM members.

Compensation based on education and related work experience, licensure and other qualifications
Health and Dental insurance (available upon starting)
Generous paid sick, personal, holiday, and vacation time
CEU benefits
Life and Disability insurance
401k with agency contribution
Wellness activity discounts
Work related travel reimbursement


Participate in key activities related to the initial comprehensive Minimum Data Sheet (MDS) assessment, completion and submission process for assigned members.
Training will be provided on the MDS process.
Complete the MDS in Enrollee’s home or preferred setting.

Establish the initial care plan, document enrollment records in eClinical Works (ECW)

Enter assessment into ECW within 24 hours of visit

Accurately maintain and adhere to MDS tracking procedures

Provide ongoing support to Care Managers and Care Team in coordinating services and completion of referrals as needed.

Evaluate medical, emotional, social problems requiring further assessment and treatment as needed.

Contribute to development of treatment planning process particularly as related to medical issues.

Establishes realistic goals; documents clear, concise plans of care; regularly updates plans of care based on change in health status.

Plan of care is made involving the client, family and team members when appropriate.

Meet with supervisor on a regular basis.

Provide home visits to clients after discharge from inpatient level of care.

Maintain updated medical records on different medical systems .

Authorize services in a timely manner.

Provide medication management, support and cueing.

Perform other related job duties as necessary.

Respects diverse views and approaches, demonstrates Standards of Respect, and contributes to creating and maintaining an environment of professionalism, tolerance, civility and acceptance toward all employees, patients and visitors.

Grade 9: Community RN: Graduate of an accredited school of Nursing with current license as a Registered Nurse in the state of Massachusetts and a Bachelors Degree in Nursing.
Home care experience, experience with disabilities and mental health preferred.
Must be comfortable seeing patients in home or similar venues.
All bilingual candidates are strongly urged to apply.
Current valid US-issued driver's license and ability to provide registered, inspected and insured automobile for work related purposes including travel between work sites
Must be able to pass a CORI background check
Community Healthlink is an Affirmative Action/ Equal Opportunity Employer. We do not discriminate in employment and personnel practices on the basis of race, sex, gender identity, age, ancestry, disability, religion, national origin, marital status, sexual preference, political affiliation or any other basis prohibited by applicable law. Hiring, transferring and promotion practices are performed without regard to the above listed items.
If applicable, Community Healthlink shall also abide by the requirements of 41 CFR 60-300.5(a) and 41 CFR 60-741.5(a). These regulations prohibit discrimination against qualified protected veterans and qualified individuals on the basis of disability. These regulations require affirmative action by Community Healthlink to employ and advance in employment qualified protected veterans and individuals with disabilities.