Job Description

Job Location: 1140 Dorchester Ave. - Dorchester, MA 02125
Position Type: Full Time 30+ hoursEducation
Level: 2 Year Degree
Travel Percentage: Negligible
Job Shift: Day
Job Category: Health CarePosition Title:                    MDS/Enrollment Registered Nurse
Department:                       PACE
Supervisor:                        Director of Growth and Enrollment
Status/Hours Per Week:   Non-Exempt / 40 hours
Primary Function:
The PACE MDS/Enrollment Nurse plays a critical regulatory role in ensuring Upham’s PACE program complies with all State and CMS clinical eligibility standards. This nurse is solely responsible for completing and submitting accurate and timely Minimum Data Set (MDS) assessments for prospective and enrolled PACE participants to meet regulatory requirements and support Upham’s fiduciary obligation to collect capitation payments. The MDS Nurse manages all clinical aspects of the intake and reassessment process, including collaboration with interdisciplinary teams (IDTs), and serves as a primary liaison to the Executive Office of Elder Affairs (EOEA)/Office of Long-Term Care (OLTC).
Duties & Responsibilities:
•    Conduct clinical home visits to assess prospective PACE participants and complete required intake documentation.
•    Perform and submit all initial and annual MDS assessments in accordance with State and CMS regulations and timelines.
•    Ensure MDS assessments are accurate, complete, and support regulatory and financial compliance, including eligibility for capitated payments.
•    Coordinate with internal departments and IDTs to provide clinical insights that inform provisional care plans and eligibility determinations.
•    Maintain communication and liaison responsibilities with EOEA/OLTC to ensure assessment and reassessment compliance.
•    Submit all required documentation to the State in a timely and organized manner, including MDS, expired assessment reassessments, and supporting documents.
•    Ensure presence and completion of required forms, including Health Care Proxy and Medical Record Form.
•    Evaluate pre-enrollees' health status and advocate for their needs and assisting in the development of the care plan.
•    Coordinate care among various healthcare Providers, including physicians, therapists, and other specialists.
•    Act as first line contact for services that support ADL and IADL needs (home care, pica, home delivered meals, AFC, DME, medical supplies.
•    Facilitate communication between the participants, their family and the IDT.
•    Provide detailed clinical information and summaries to IDTs to support transition and care planning for new enrollees.
•    Organize and maintain tracking systems to monitor upcoming reassessments and submission deadlines.
•    Collaborate with the Director of Growth and Enrollment on presentations to vendors, hospitals, and external agencies to promote the benefits of the PACE model.
•    Act as a liaison with Upham’s Corner Health Center and Upham’s Home Health Care to help identify patients who may meet PACE clinical eligibility criteria and support internal referrals.
•    Participate in and contribute to quality improvement initiatives related to Intake and Enrollment workflows and outcomes.
•    Participate in CMS and MassHealth audits, including preparation, documentation, and on-site support as needed.
•    Uphold organizational and regulatory standards related to confidentiality, safety, and culturally competent care.
•    Adhere to UCC’s standards of Employee Conduct, including customer service, respect, non-discrimination, privacy, and attendance.
•    Maintain confidentiality of all patient and employee records and information.
•    Follow safety protocols and participate in all required training, including PACE-specific annual education.
•    Perform other duties as needed.

QualificationsMinimum Basic Knowledge:
•    Current MA Registered Nurse (RN) license and active BLS certification.
•    Knowledge of ADL/IADL assessments and skilled nursing criteria.
•    Valid MA driver’s license with current automobile insurance required.
Experience &

Qualifications:
•    Minimum of two years of experience working with an elder population.
•    Strong understanding of PACE program requirements and regulatory guidelines.
•    Experience with ICD-10 coding and clinical documentation best practices.
•    Familiarity with electronic health data systems (e.g., PACE Care Online, OCHIN, EPIC).
•    Competent with Microsoft Office applications (Excel, Word, PowerPoint).
•    Excellent organizational, written, and verbal communication skills.
•    Ability to work independently and collaboratively across teams.
•    Bilingual language skills preferred (English/Spanish, Portuguese Creole, or French Creole).
•    Home care or community health experience preferred.
Independent Action:
•    Independently completes timely and compliant MDS assessments.
•    Maintains organized systems for monitoring and reporting MDS activities.
•    Serves as the key point of contact between EOEA/OLTC and Upham’s PACE program for clinical assessment matters.
Supervisory Responsibility:
None
Define Access Level to PHI:  Level 4: Authorized to access full health information. UCC position and job responsibilities involve the provision of patient care and working as a clinical team member. Staff in this category level, although allowed full access, should only access the necessary information for each respective treatment encounter/circumstance.