Elder Services of the Merrimack Valley
  • 22-Nov-2021 to Until Filled (EST)
  • Nursing
  • Danvers, MA, USA
  • Full Time

Full benefits package available


A great opportunity for those seeking work life balance! NO NIGHTS, NO WEEKENDS, NO HOLIDAYS!!!

About Us: Since 1974 our agency has strived towards supporting an individual's desire to make their own decisions, secure their independence and remain living independently in the community. We are proud of our employees who make this possible every day. Our agency is a thought-leader, a nationally known generator of new ideas, because it welcomes creativity, your ideas. It is an outstanding place to work' stimulating, friendly, collaborative. We offer competitive salaries, generous vacation time, and an excellent work/life balance. We value diversity and encourage career growth. If you have a passion for improving the lives of the elderly community and enjoy working in a diverse team driven by its mission, you've found the right place!

Position Responsibility: The Home Care Registered Nurse is responsible for participating in the interdisciplinary approach to case management of elders living in the community. The Home Care Registered nurse facilitates the transition of consumers to and from the nursing facility. This includes assessing for, monitoring, and authorizing personal care services as well as determining clinical eligibility for community programs. The Home Care Registered Nurse develops community care plans for elders in accordance with the guidelines set by the Executive Office of Elder Affairs, MassHealth, and agency standards.

The LTSS RN Assessor is responsible for completing comprehensive assessments for those consumers identified for various programs, as well as providing an interdisciplinary approach to care planning for consumers residing in community settings. The Nurse Assessor develops community care plans for elders in accordance with the guidelines set by the program regulations or contract.

Essential Functions:

  • Perform on-site evaluation of consumers in both the community residence and in nursing facilities, including review of medications and a clinical assessment.
  • Conduct field visits to assess an older adult's physical, social, emotional, and environmental status to determine their eligibility and needs in their homes.
  • Complete a comprehensive assessment and a basic care plan based on the unmet needs that were identified during the assessment -working with the consumers and involved supports to develop a service plan which addresses the consumer's needs, values and preferences.
  • Participate on an interdisciplinary team of Registered Nurse, Case Manager and Program Manager; attend appropriate case consultations and conferences.
  • Work collaboratively to develop complex care plans and enhanced service plans according to high risk protocols with the goal to diminish barriers to receiving services.
  • Determine clinical eligibility for MassHealth recipients or 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.
  • Assess, implement and monitor the appropriateness of Personal Care/Homemaker services.
  • Provide education of health and wellness resources to consumers and families.
  • Complete necessary electronic documentation determining/supporting the level of care for community services and/or nursing facility placement according to the clinical program, the Executive Office of Elder Affairs and MassHealth regulations.
  • 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.

Additional functions

  • Attend appropriate agency and community meetings.
  • Participate in agency committees, enhancing the effectiveness and quality of the clinical component of assessed needs.


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 a plus.

Hours: 37.5 per week


ESMV/NS is strongly committed to fostering a professional environment that recognizes, respects, and encourages the unique contributions of a broad spectrum of qualified employees. It is important that our employees reflect the diverse communities we serve. We maintain a work atmosphere that allows people of varied backgrounds to grow professionally and contribute to our mission by promoting diversity, equity, inclusion, and work-life balance.

Elder Services of the Merrimack Valley
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