Registered Nurse

Provide nursing admissions, comprehensive assessments and ongoing clinical oversight for assigned members. Direct assigned LPN clinical work, educate caregivers and coordinate with Case Managers and Operations to maintain safe, compliant and continuous care.

The responsibilities listed below represent the essential functions of the position and are not intended to be an exhaustive list of all duties, responsibilities, or qualifications associated with the role.

• Perform assigned RN admissions, initial and ongoing nursing assessments, semiannual and annual evaluations and other required nursing visits within established timeframes.
• Review available clinical history, primary care provider summaries, diagnoses, medications, functional needs and identified risks to establish an accurate clinical picture.
• Develop, implement, review and update nursing components of the plan of care in collaboration with the member, caregiver, Case Manager and healthcare team.
• Assess changes in condition, reconcile medication information within RN scope and coordinate timely follow-up with the primary care provider and appropriate clinical resources.
• Provide a complete admission handoff to the Case Manager and Regional Manager so ongoing visit cadence and support can begin without gaps.

• Provide and document caregiver orientation, skills education, reinforcement and competency follow-up as required by the member’s plan and program standards.
• Assess caregiver understanding, performance and support needs; address identified care or safety concerns through education and escalation.
• Review assigned caregiver logs at least every 30 days, including between nursing visits; evaluate discrepancies against clinical assessments and the plan of care.
• Provide clinical direction, supervision and review of assigned LPN activities, including follow-up on escalated concerns and documentation of required oversight.

• Communicate significant health changes, urgent concerns and potential service interruptions promptly to appropriate clinical and operational leaders.
• Coordinate with Case Managers, caregivers, providers and regional teams regarding hospitalizations, transitions, changing needs and discharge planning.
• Complete required nursing progress notes, reports and semiannual health-status communications to the primary care provider accurately and on time.

• Coordinate with Regional Operations, nursing, Caregiver Experience, Scheduling, Credentialing, Medical Records and Compliance to resolve service barriers and ensure accurate handoffs.
• Document escalations, identify accountable owners and follow through until issues are resolved; communicate emerging risks before they interrupt services.
• Collaborate with Scheduling to coordinate nursing admissions, assessments, follow-up visits and caregiver availability; communicate clinical priorities and changes while supporting efficient field routing.
• Assess and document clinical and safety factors affecting the suitability of the home setting, including member needs, caregiver capabilities, emergency preparedness and environmental risks; coordinate qualified-setting concerns with the Case Manager and regional leadership.
• Provide clinical input and practical support to case management, including evaluation of changes in member condition, caregiver training needs, service barriers and appropriate care-plan revisions.
• Work with the Case Manager and Scheduling to address missed visits, caregiver transitions and changes in home readiness before they disrupt safe service delivery.

• Maintain timely, accurate and complete records in approved systems, including assessments, visits, communications, outstanding actions and resolutions.
• Follow established standard operating procedures, confidentiality requirements and documentation standards; identify recurring gaps and recommend practical workflow improvements.
• Participate in quality reviews, required training, competency evaluations and periodic field shadowing; use performance data and feedback to improve service quality.

• Perform duties primarily in members’ homes and other assigned field locations. The Braintree, Massachusetts office is the organizational base; office attendance is limited to required training, meetings or other specifically requested activities.
• Build professional, supportive relationships with members and caregivers through in-person visits; listen to concerns, provide practical guidance within role scope and ensure issues reach the appropriate team promptly.
• Work directly with the Regional Manager and Regional Director to share meaningful case observations, caregiver concerns, service barriers and opportunities to improve member outcomes and continuity of care.
• Provide timely, actionable case insights to the Case Manager, Regional Manager, Regional Director, and other appropriate clinical and operational leaders, as applicable and contribute to the creation, implementation and updates of individualized plans of care within professional scope.
• Plan field visits geographically and coordinate schedules to reduce unnecessary travel, protect member-facing time and meet required visit windows without compromising care quality.
• Maintain accurate mileage records and submit mileage expense reports with required trip details, supporting documentation and approvals in accordance with company policy; promptly resolve discrepancies.
• Keep field notes, case updates and follow-up assignments organized in approved systems; communicate key findings and outstanding needs across departments while safeguarding confidential information.

• Current, unrestricted Registered Nurse license issued by the Massachusetts Board of Registration in Nursing.
• Must maintain an active, unrestricted Massachusetts Registered Nurse license throughout employment.
• At least two years of recent direct-care experience with elders or adults with disabilities.
• Strong nursing assessment, clinical judgment, caregiver education, documentation and interdisciplinary coordination skills.
• Ability to travel within assigned regions; valid driving credentials and reliable transportation where required.
• Additional language skills preferred.
• Proficiency with Microsoft Office applications, mobile devices, and electronic documentation systems.
• Employment is contingent upon successful completion of all required pre-employment screenings, including license verification, background checks, reference checks, and any program or regulatory requirements applicable to the position.

• Required nursing admissions, assessments and visits completed within required windows.
• Complete, accurate and timely nursing documentation and provider reports.
• Caregiver logs reviewed within every required 30-day cycle.
• Required RN supervision, LPN reviews and follow-up actions completed on time.
• Caregiver education, competency follow-up and clinical escalations documented and completed.
• Quality and timeliness of case insights, plan-of-care contributions and escalations to the Regional Manager and Regional Director.
• Efficient field-route planning, accurate mileage documentation and on-time expense report submission.
• Effective collaboration with Scheduling, timely resolution of home-readiness concerns and documented case management support within the role’s scope.

This is a field-based position involving regular travel between member homes and community settings, variable home environments, standing, walking, sitting, computer and mobile-device use, and direct member and caregiver interactions. The organizational office is in Braintree, Massachusetts; office attendance is only as needed for required training or specifically requested meetings. Field routes should be organized efficiently, with accurate mileage reporting in accordance with company policy. Essential duties are performed with reasonable accommodation where applicable.

Maintain confidentiality; comply with all applicable federal and state regulations, organizational policies, accreditation standards, and program requirements; participate in required training; and perform other related duties consistent with the position and professional scope as assigned. Vitra Health is an equal opportunity employer.

Vitra Health is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, age, disability, veteran status, genetic information, sexual orientation, gender identity, or any other protected status under applicable law.

This job description is intended to describe the general nature and level of work performed by an employee in this position. It is not intended to be an exhaustive list of all duties, responsibilities, or qualifications. Vitra Health reserves the right to modify, assign, or remove duties and responsibilities as business needs require.

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