Community-Based RN: Home Care & Care Coordination

America Health and Home Care; Maplewood (MA); On-site; USD 85,000 - 110,000; Full time

Job summary

America Health and Home Care is seeking a qualified Registered Nurse (RN) to provide nursing assessments, care coordination, and health monitoring for adults enrolled in MassHealth AFC. You will work with the Care Manager and the interdisciplinary team to ensure person-centered care that supports community living.

Applicants must hold an active MA RN license, have CPR, be willing to travel to members’ homes, and be proficient with electronic health records.

Qualifications

• Active, unencumbered Massachusetts RN license.
• Minimum of one year clinical experience.
• CPR certification.
• Proficiency with electronic health records.

Responsibilities

• Conduct initial and ongoing nursing assessments using MassHealth-approved tools.
• Develop, implement, and monitor individualized care plans.
• Conduct home visits every 30–60 days based on level of care.
• Collaborate with Care Managers to review and update care plans.
• Educate members and caregivers on medical conditions and medication management.
• Coordinate with physicians, specialists, and community resources.
• Monitor health status changes and initiate interventions.
• Complete documentation in compliance with MassHealth AFC regulations.
• Participate in interdisciplinary team meetings.
• Ensure caregiver competency through training and evaluations.
• Respond promptly to medical emergencies.

Skills

Interpersonal skills

Communication skills

Organizational skills

Tools

EHR systems

Job description

America Health and Home Care is seeking a qualified Registered Nurse (RN) to provide nursing assessments, care coordination, and health monitoring for adults enrolled in MassHealth AFC. You will work with the Care Manager and the interdisciplinary team to ensure person-centered care that supports community living.

Applicants must hold an active MA RN license, have CPR, be willing to travel to members’ homes, and be proficient with electronic health records.