Elder Services of the Merrimack Valley
  • 02-Nov-2020 to Until Filled (EST)
  • Nursing
  • Danvers, MA, USA
  • Full Time

Full benefits package available



Position Responsibility: The  Home Care Registered Nurse is responsible for participating in the interdisciplinary approach to case management of elders living in the community and facilitating the transition from nursing facility back to the community. This includes assessing, monitoring and authorizing personal care services as well as screening for short-term or long-term nursing facility placement. The Home Care Registered Nurse develops community care plans for elders in accordance with the guidelines set by the Executive Office of Elder Affairs, the Clinical Assessment and Eligibility of Care Agreement, and other contracts. Employee will report to the Danvers office. 


Essential Functions: (Core duties or tasks fundamental and not marginal to the performance of the job)

  • Assess, implement and monitor the appropriateness of Personal Care/Homemaker services.
  • Perform on-site evaluation of consumers in both the community and in nursing facilities, including reconciliation of medications and a head-to-toe clinical assessment.
  • Participate in an interdisciplinary team of Registered Nurse, Case Manager and Program Manager; attend appropriate case consultations and conferences.
  • Develop complex care plans and enhanced service plans according to high risk protocols with the goal to diminish barriers to receiving services.
  • Screen applicants for nursing home placement, adult day health, home- and community-based waiver services, and other community-based programs.
  • Assist in the coordination of discharge planning for appropriate elders from the nursing facility setting to the community, including service planning.
  • Work with the consumers and involved supports to develop a service plan which addresses the consumer's needs, values and preferences.
  • Complete necessary electronic documentation determining the level of care for community services and/or nursing facility placement according to the Executive Office of Elder Affairs and MassHealth regulations.
  • Attend appropriate agency and community meetings.
  • Participate in agency committees, enhancing the effectiveness and quality of the clinical component of assessed needs.
  • Provide education of health and wellness resources to consumers and families.
  • Support ASAP nursing team with coverage as needed.
  • Perform additional tasks as directed by the Nurse Manager, including piloting, implementing, and evaluating new programs as they are developed.


Qualifications: A valid Massachusetts Registered Nurse license is required. Applicants must have a valid driver's license and reliable transportation. The combination of education level and related experience required is as follows:

  • a Bachelor of Science in Nursing or Associate of Science in Nursing degree and at least one (1) year of clinical experience and/or nursing in a community or long term care setting; or
  • a Diploma RN and two (2) additional years of community-based nursing experience or long-term care direct service experience

Must be willing and able to community assessments on a regular basis and possess good written, verbal, interpersonal and computer skills and the ability to work in an interdisciplinary team-based environment. Bilingual ability in Spanish or Khmer a plus.


Hours: 37.5 per week


Elder Services of the Merrimack Valley
  • Apply Now

  • * Fields Are Required

    What is your full name?

    How can we contact you?

  • Sign Up For Job Alerts!

  • Share This Page
  • Facebook Twitter LinkedIn Email
Logo Home Event Info News Contact f search about Programs involved give