About the Role: ***THIS IS AN IN HOME COMMUNITY BASED POSITION*** Coverage Area: Boston, Mattapan, Hyde Park, Dorchester, South Boston Our company is growing, and we believe that our team is the key to our success. That is why we are looking for an in-home RN to support our clients in the Boston area. If you're a passionate, caring, motivated professional who is looking to become part of an awesome organization while making a difference in your community, we encourage you to apply today! VITRA Health is vital in providing comprehensive assistance to caregivers who care for friends and family in their own homes. We understand that most caregivers face financial and emotional challenges, often without compensation or support for their selfless efforts. By joining us, you can be part of the solution to these challenges. If you have a positive attitude and love helping people, VITRA Health is for you. Our highest priority is our team's health, happiness, and success. Essential Functions * Conduct regular in-person visits with client and caregiver in a qualified setting to ensure clients remain safe and healthy in the community while decreasing/preventing unnecessary hospitalizations and re-hospitalizations. * Collaborate with the Care Manager in reviewing, collecting, and uploading the Care Communication Tools (CCT) at the time of each visit, to ensure full compliance with program regulations. * Evaluation of all potential clients; assessments and admissions of clients; Completion of all components of the client's assessment forms. * Conducting orientation for each new caregiver before the caregiver begins personal care; and providing ongoing training health, aging and other related topics. * Completing a nursing progress note corresponding with each encounter, or more often as the member's condition warrants. * Select, train, evaluate, and supervise AFC/FGAFC caregivers in conjunction with the care manager. * Ongoing evaluation of client's health status, safety in the community, potential resources needed. Ongoing evaluation of program eligibility, including formal semi-annual and annual assessments. * Complete required visit and assessment documentation including: Health Status Form, Minimum Data Sheet, Multidisciplinary Care Plan and other documentation as required. * Monitoring of the client's health status and completion of the semi-annual client health status report (PSF), the annual MDS, RFS, the client care plan and all other applicable clinical assessments. * Work collaboratively with the interdisciplinary team to create, monitor and implement client-centered Plan of Care (POC). Planning for and implementing safe discharges and transitions to and from Vitra administered programs. * Report observations and functioning status of the clients in the internal charts and report changes in the health status of any member to the member's PCP. * Follows all AFC and FGAFC policies and procedures when delivering care. * Performs any other additional duties that may be required by management at any time. Education, Experience and Licensure Requirements + Licensed by the Massachusetts Board of Registration in Nursing + Must have at least two years of recent experience in the direct care of elders or adults with disabilities + Excellent interpersonal and communication skills required + Valid driver's license with proof of insurance required + Bilingual in English and Spanish strongly preferred + Relevant experience, preferably in healthcare, home health care, case management, or sales preferred + Previous experience with mental health aspects of care + Strong communication, writing, organizational, and time management skills + Solution-oriented with the ability to multitask + Proficiency with the Microsoft Office Suite About Us: Vitra Health is a Home Health Care and Adult Day Health organization that specializes in care management of adults and seniors. We are a rapidly growing company that was started to improve access to quality home health care services. We rate ourselves solely by the quality of care we provide our clients. We realize that our clients are someone's parent, grandparent, child, friend, or neighbor – we pride ourselves on never taking this fact for granted.