Mobile Home Health RN: Complex Care & Care Coordination

CareSource; Massachusetts; On-site; USD 63,000 - 100,000; Full time

Job summary

CareSource is seeking a Care Delivery RN in Massachusetts to collaborate with an interdisciplinary team to provide primary care, in-home specialty care, and care coordination for high-risk, complex patients requiring intensive support.

The role emphasizes care management, patient follow-up, and close coordination with PCPs and external providers to ensure comprehensive, patient-centered plans and outcomes.

Qualifications

• Associates degree in nursing is required; Bachelor's degree preferred.
• Five (5) years of RN experience in a high-touch clinical environment or home care.
• Two (2) years of experience caring for patients with complex medical, behavioral health, and social needs.
• Three (3) years in outreach or community care for patients with complex needs is preferred.

Responsibilities

• Deliver care management and care coordination to complex patients within an interdisciplinary team.
• Conduct basic health assessments and provide RN-level nursing care within scope of practice.
• Escalate pertinent clinical findings to the assigned APC within required timeframes.
• Follow up with patients by phone to ensure satisfaction and adherence.
• Assess and address quality gaps with the care team to close identified gaps.
• Coordinate timely post-hospital discharge activities to reduce readmissions.
• Document visits with clear, comprehensive charting and adherence to policies.
• Communicate plans and loop closures to the care team and PCP.

Skills

Communication skills

Nursing judgment

Time management

Interdisciplinary collaboration

Education

Associates degree in nursing

Bachelor's degree in nursing

Tools

EMR system

Microsoft Office

Job description

CareSource is seeking a Care Delivery RN in Massachusetts to collaborate with an interdisciplinary team to provide primary care, in-home specialty care, and care coordination for high-risk, complex patients requiring intensive support.

The role emphasizes care management, patient follow-up, and close coordination with PCPs and external providers to ensure comprehensive, patient-centered plans and outcomes.