Overview About us: Fallon Health is a company that cares. We prioritize our members--always-making sure they get the care they need and deserve. Founded in 1977 in Worcester, Massachusetts, we deliver equitable, high-quality coordinated care and are continually rated among the nation’s top health plans for member experience, service, and clinical quality. Fallon Health’s Summit ElderCare® is a Program of All-Inclusive Care for the Elderly–PACE for short. PACE, an alternative to nursing home care, is a program that helps people 55 and older continue living safely at home. At Fallon Health, we believe our individual differences, life experiences, knowledge, self-expression and unique capabilities allow us to better serve our members. We embrace and encourage differences in age, race, ethnicity, gender identity and expression, physical and mental ability, sexual orientation, socio-economic status and other characteristics that make people unique. Today, guided by our mission of improving health and inspiring hope, we strive to be the leading provider of government-sponsored health insurance programs—including Medicare, Medicaid, and PACE— in the region. Brief Summary of purpose Responsible for the effective management and delivery of direct nursing care to PACE participants in any setting utilizing nursing process and adhering to standards of nursing practice. Responsibilities Primary Job Responsibilities • Primary nurse not only has the responsibility for the participant, but the authority to advocate for the best care for the participant unique to their situation. • Fostering a relationship with the caregiver and participant. • Primary Nurse will take on a Leadership Role. • Effectively communicate with the healthcare team. • Assigns tasks and duties to the healthcare team; ensure the tasks are completed; responsible for their panel. • Develops an individualized plan of care. • Accountability for assessments, communicating needs and coordinating the care team. • Primary nurse develops the plan of care • Reviews and implements Provider’s orders. • Conducts nursing assessments according to policy guidelines including physical, psychosocial, behavioral, and MDS-HC as indicated. • Involves participants and significant other(s) based on needs and abilities. • Delivers care to participants in any setting, including skilled services, based on individualized needs and according to age-appropriate nursing standards. • Provides for cultural and diverse needs of participants when providing care. • Monitors and evaluates therapeutic interventions. • Delegates and or accepts participants’ care responsibilities to other members of the health care team, when appropriate. • Identifies emergency situations and initiates appropriate nursing orders/interventions. • Meets the needs of participants in a timely manner. • Participates in the interdisciplinary team (IDT) process and collaborates with IDT members to meet the needs of participants. • Consistently documents all aspects of participant care, including significant changes in health status, monthly nurses’ notes and health care teaching in the medical record. • Participates in training and orientation of new nursing staff as assigned. • Assists in the delivery of other nursing services as assigned. • Participates in the nursing “on-call” rotation as assigned. • Initiates and completes falls, infection, grievance and incident reports • Participates in CMS calls when deemed necessary. • Active participant in the site specific committees. • Participates in the post IDT huddle and any other additional meetings • Any additional tasks deemed necessary by the Clinical Nurse Manager and or Site Director. • Assumes the role of the home care nurse, floor or triage nurse per the direction of the Clinical Nurse Manager or Site Director as appropriate. • Performs all duties in accordance with FCHP and Summit ElderCare policies and procedures. • Functions independently to administer medications and treatments as ordered by the provider. Functions independently in the primary nurse role. Independent in performing a nursing assessment and executing the plan of care in all settings the participant maybe in. • Medication administration • Performing bladder scans, EKG, Point of Care, and glucometer testing Qualifications Education: • Graduate of an accredited school of nursing License/Certifications: • Current license as an RN in the state of Massachusetts • CPR and Alzheimer’s certification, or willingness to be certified within 60 days of hire, is essential.  • Access to reliable transportation to perform work throughout the PACE center’s service area (30-mile radius) when needed. Willingness to occasionally assist other SE PACE centers either in person or remotely, as appropriate, when there is an opening or a gap in coverage Experience: • At least two years of recent experience in the direct care of adults or chronically disabled persons with at least one year caring for a frail or elderly population. Ambulatory care or home care experience helpful. • Ability to use an electronic medical record. Other: • Reliable Transportation Required Pay Range Disclosure: • In accordance with the Massachusetts Wage Transparency Act, the compensation for this position is $96,000 per year, which reflects what we reasonably and in good faith expect to pay at the time of posting. Final compensation will depend on the candidate’s experience, skills, and fit with the role’s responsibilities. Fallon Health provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.