Position Summary: The Registered Nurse (RN) provides nursing assessments, care coordination, and health monitoring services to members enrolled in the Adult Foster Care (AFC) Program in accordance with MassHealth AFC regulations. The RN collaborates with the Care Manager and interdisciplinary team to ensure each member receives person-centered, comprehensive care that supports their ability to remain safely in the community.

Responsibilities:

Conduct initial and ongoing nursing assessments of members using MassHealth-approved tools.
Develop, implement, and monitor individualized care plans.
Conduct home visits to assess the health status and safety of members at least every 30- 60 days based on Member’s Level of care.
Collaborate with Care Managers to review and update care plans regularly.
Educate members and caregivers regarding medical conditions, medication management, and health maintenance.
Coordinate with physicians, specialists, and community resources as needed.
Monitor changes in members' health status and initiate appropriate interventions.
Complete all required documentation accurately and timely in compliance with MassHealth AFC regulations.
Participate in interdisciplinary team meetings.
Ensure caregiver competency through training, coaching, and annual evaluations.
Respond promptly to medical emergencies or significant changes in members' condition.

Qualifications:

Active, unencumbered Massachusetts Registered Nurse (RN) license.
Minimum of one year of clinical experience required, preferably with elders, persons with disabilities, or chronic conditions.
Knowledge of MassHealth Adult Foster Care program regulations preferred.
Ability to conduct thorough clinical assessments.
Strong interpersonal, communication, and organizational skills.
Ability to travel to members' homes throughout assigned territory.
CPR certification.
Valid driver's license and reliable transportation.
Proficiency in using electronic health records and basic computer systems.

Physical Requirements:

Ability to safely navigate home environments.
Ability to lift up to 25 lbs occasionally.

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