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Registered Nurse (RN)

Position Summary:  An ASAP RN assess clients for services, determine clinical eligibility for programs and develop care plans. Our primary goal is to support individuals who receive services in the community so they can continue living in their own home. Duties include data entry into computer database, communication and consultation with family members, other Montachusett Home Care staff and community professionals.

Role and Responsibilities

  • Participates as an integral member of a home care team which, along with case managers and other related personnel, assesses and/or authorizes services to be delivered by long term care agencies with the aim of promoting coordination and cooperation in the formation of cost effective and quality service plans.  The ASAP RN will participate in determining clients’ initial and continued eligibility for Home Care and Medicaid funded services.
  • Participates and oversees the Personal Care (PC) Service Program according to EOEA regulations.  The ASAP RN assesses clients for personal care, develops the P. C. care plan, and monitors the plan on a regular basis for appropriateness of the care plan and amount of service.
  • Oversees the Vendor RNs supervision of Personal Care Homemakers. May provide demonstration orientation to vendor staff in emergencies.
  • Evaluates and/or responds to client emergencies as necessary.
  • Conducts the Clinical Assessment and Eligibility screenings for Medicaid recipients or applicants: Acute and Chronic Hospital Nursing Facility Pre-Admission, Community screenings, Adult Day Health screenings, and Initial and Reassessment 2176 Waiver screenings
  • Participates in the Comprehensive Service and Screening Model (CSSM) to evaluate, screen, and develop service plans, including on-site nursing home visits and face to face evaluations to reduce MassHealth length of stays in nursing homes.
  • ASAP RN who visit local NF weekly (CSSM RN) will also attend 2x/wk Core Team meetings with ASAP Nurse Manager, Home Care Supervisor and assigned CSSM CM to discuss NF residents and their discharge planning activities / needs.
  • Considers appropriate and available community options for all applicants for nursing home screenings to determine if appropriate service planning can provide an effective alternative to nursing home placement.  Options include but are not limited to State Home Care, Adult Family Care, Group Adult Foster Care,   Enhanced Community Options Program, Choices Program, PCAs, Assisted Living Facility, Home Health Services and Rest Home Placements.
  • Provides Information and assists clients and/or families to explore alternatives to nursing facility placement whenever it is appropriate.
  • Participates in interdisciplinary RN/CM team meetings and case conferences.
  • Participates with CM and Supervisor in determining appropriateness for referral of State Home Care clients or applicants to any of the programs offered through MHCC.  Referrals are then made for the Choices Program, Enhanced Community Options Program, Medicaid Waiver Program, Home Health Services, GAFC, AFC, PCA, or Congregate Housing Program.
  • Provides consultation and in-service training to staff, provider agencies and other community agencies.
  • Submits reports and statistics as requested.
  • Serves on after-hours on-call team to respond to consumer needs.
  • Performs other duties as assigned.

Qualifications and Education Requirements

  • It is required that this individual has a current license as a Registered Nurse from the Massachusetts Board of Registration in Nursing. 
  • RN should have a Bachelor of Science degree in Nursing or Associates of Science degree in Nursing and have at least one year of clinical experience and or nursing in a community or long term care setting or;
  • RN should have a Diploma RN and two additional years of community-based nursing experience or long term care direct service experience. 
  • They should have experience and interest in the elderly population and/or community health.  They should possess:  good communication, organization and management skills; good nursing assessment skills; good judgement and decision making skills; and excellent documentation
  • Knowledge of basic medical, mental health, social service delivery systems, as well as acceptable record keeping practices is essential.
  • A valid driver's license and a legally insured and registered motor vehicle are required, a copy of current license and registration will be on file in the personnel record.

Essential Functions:


  • Visual, speaking, auditory and mobile capacity necessary:
  • Capacity to see computer screen, read written material, and drive a car.
  • Capacity to hear and speak on the telephone.
  • Capacity to communicate verbally with consumers, caregivers, supervisors and managers.
  • Capacity for fine manipulation in the frequent use of office equipment such as computers, copy machines, fax machines, telephones, calculators, etc.
  • Capacity to drive in all-weather to visit consumers in their homes
  • Capacity to navigate uneven terrain in all-weather to visit consumers in their homes
  • Capacity to climb stairs
  • Ability to sit or stand for extended periods of time.
  • Occasional reaching and grabbing objects with both hands, twisting of hand and wrist, and pushing and pulling of objects.
  • Occasional bending, squatting, and twisting to perform work functions.
  • Occasional capacity to lift up to 25 pounds.


  • Ability to understand and/or interpret complicated program instructions and laws.
  • Capacity to learn complicated computer software
  • Capacity to deal rationally and calmly with varying personalities
  • Capacity to work well in fast paced, rapidly changing environment.         


  • Work is split between indoor office work and traveling outdoors to meetings, trainings and consumers’ homes.
  •  Must be able to tolerate odors and pollutants including but not limited to smoke, air fresheners, pet dander, personal odors, etc. from a variety of in-home conditions.
  • Must be able to tolerate by-products of office machine operation.
  • Must be able to tolerate heat and cold of seasonal changes and indoor temperatures.
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