Field RN - MDS Assessments

Activate Care; United States; On-site; USD 72,000 - 95,000; Full time

Job summary

Activate Care in Massachusetts seeks a full-time RN to perform in-home clinical assessments and field visits, document SDOH needs, and coordinate with care teams to drive interventions. The role requires strong clinical judgment, field experience, and comfort with EMR systems, with travel across Massachusetts and a valid driver’s license.

You will conduct intake assessments, complete screenings (PHQ-9, DAST, etc.), provide medication coaching, and ensure compliance with MassHealth and Medicaid

Qualifications

• Active RN license in Massachusetts
• Minimum 1 year clinical experience (home health preferred)
• Experience with HIPAA-compliant healthcare settings and EMR

Responsibilities

• Conduct in-person assessment visits and clinical exams across MA.
• Perform medication coaching and reconciliation; address adherence concerns.
• Complete screenings (PHQ-9, DAST, EASI, etc.) and MDT scheduling as needed.
• Document interactions using EMR and claims systems.
• Refer to behavioral health and long-term services as appropriate.
• Travel throughout Massachusetts and maintain driver’s license.

Skills

RN license MA

Home health experience

EMR proficiency

Communication skills

Bilingual English/Spanish

Education

Associate Degree in Nursing

Bachelor’s in Nursing preferred

Tools

EMR systems

Microsoft Office

Job description

** This is a FULL TIME, HYBRID role where applicants should reside within 30 minutes from Boston, MA to be strongly considered for this position. *

About Activate Care:

At Activate Care, we’re on a mission to improve health equity and drive improved health outcomes across the country. Our Community Care Record platform, Care Link, enables healthcare and community organizations to coordinate care for populations challenged with health-related social needs (HRSN). Path Assist is our tech-enabled Community Health Worker program for addressing HRSN utilizing an evidence-based, structured intervention. Our goal is simple: address individuals’ unmet HRSNs, increase health confidence, improve self-efficacy, and reduce inappropriate healthcare spend.

Role Overview:

The RN conducts high-quality, timely in-person clinical assessments in members’ homes and in community settings across Massachusetts. Using clinical judgement, the position will complete intake assessments, notating SDOH needs, while maintaining compliance with MassHealth and Medicaid, SNP member guidelines. This role identifies unmet medical, behavioral, and social needs and collaborates with internal care teams to drive appropriate interventions. The position requires strong clinical judgment, field-based experience, and comfort with electronic health record systems.

Responsibilities:

• Conduct in-person assessment visits and clinical exams, including relevant screenings within assigned territory.
• Perform medication coaching and reconciliation, identify adherence concerns, and provide patient education on acute and chronic diseases.
• Complete screeners such as PHQ-9, EASI, Audit, and DAST, and Minimum Data Set- Home Care as needed.
• Prioritize and escalates members with urgent needs to RN Supervisor or manager promptly.
• Use electronic health record and claims systems to document and track member interactions and care needs.
• Ensure timely referrals to behavioral health and long-term services as appropriate.
• Manage scheduling and tracking of assessments to ensure timely completion.
• Participate in quality improvement activities and maintain clinical competencies.
• Maintain effective communication and a constructive work environment with team members.
• Comply with organizational policies, privacy regulations, and documentation standards.
• Provide clinical assessments via telehealth when appropriate.
• Continuously assess member’s engagement within the designated care pathway, and determine program fit.
• Collaborate with care, decision makers to ensure program alignment.
• Other duties as assigned.

Requirements

Qualifications & Skills:

• Associate Degree in Nursing required; Bachelor’s in Nursing preferred.
• RN license in good standing in the Commonwealth of Massachusetts.
• Minimum of 1 year clinical experience (including clinical rotations).
• Experience working in HIPAA-compliant or healthcare settings.
• Experience with electronic medical records (EMR).
• Prior experience in care management or managed care.
• Ability to conduct independent assessments and escalates clinical concerns appropriately.
• Strong organizational, communication, and interpersonal skills.
• Intermediate to advanced proficiency in Microsoft Office and EHR platforms.
• Able to work independently in the field and navigate shifting priorities.
• Willing to travel throughout Massachusetts with a valid, unrestricted driver’s license.
• Comfortable with technology and remote collaboration platforms.
• Candidates with bilingual proficiency in English and Spanish are strongly encouraged to apply

Diversity & Inclusion:

At Activate Care, we are committed to providing an environment of mutual respect where equal employment opportunities are available to all applicants and teammates without regard to race, color, religion, sex, pregnancy (including childbirth, lactation, and related medical conditions), national origin, age, physical and mental disability, marital status, sexual orientation, gender identity, gender expression, military, and veteran status, and any other characteristic protected by applicable law. Activate Care believes that diversity and inclusion among our teammates is critical to our success as a company, and we seek to recruit, develop, and retain the most talented people from a diverse candidate pool.

The organization is committed to providing reasonable accommodations to qualified individuals with disabilities throughout the hiring process. If you require an accommodation to participate in the interview process, please let our team know at the time of scheduling.

The Company will not sponsor applicants for work visas at this time.