The Team Nurse coordinates health care access and management for individuals with mental health conditions using a person-centered approach. Responsibilities include conducting physical health assessments, overseeing MAP compliance, and training staff on health matters.
Overview The Adult Clinical Community Supports (ACCS) Team Nurse (Registered Nurse) promotes the full integration and functioning of Persons Served (PS) needed to live a healthy life in the community.
Utilizing a holistic, person-centered approach, the Team Nurse will coordinate access to and management of health care for PS.
The Team Nurse will work in conjunction with Care Coordination entities and all associated medical and behavioral health providers.
Additionally, the Team Nurse will monitor and consult with team members regarding the medical and psychiatric conditions of PS.
The Team Nurse will also develop the delivery of health promotion strategies for modifiable risk factors by the Team and oversee Medication Administration Program (MAP) compliance for Team and associated residential Group Living Environments and Supported Independent Environments.
The essential job duties/responsibilities of the position include but are not limited to the information listedbelow:
Meet with and conduct assessment of physical health of each PS served by the Team annually.Update assessment when significant medical status changes occur.
Educate and train direct service staff on pertinent health matters regarding PS condition,diagnosis(s), medication and signs and symptoms of chronic, acute and urgent physical health issues(e.g. Diabetes, HTN, CHF, COPD, Vital signs management).
Consult with team members on medical and nursing needs of PS.
Participate as member of intervention team for assigned PS.
Monitor and communicate PS needs for, and coordinate PS access to, health care with CareCoordination entities and all associated medical and behavioral health providers as needed.
Facilitate referrals to community providers as needed with Care Coordination entities.
Attend hospital discharge meetings when significant medical issues are present, advocate forrehabilitative stay if needed, and obtain hospital discharge summaries at time of discharge.
Educate and support PS families and friends (following HIPAA authorization protocols) regarding PSneeds and preferences as they relate to health care.
Complete Nursing and Health Assessments in the community for PS as assigned.
Engage PS in personal health promotion activities targeted at modifiable risk factors. Use recoveryoriented,person-centered, motivational interviewing, harm-reduction, trauma-informed, culturallycompetent, and strengths-based approaches to help PS think through their current healthcircumstances, consequences and interest in change.
Design, facilitate and oversee health promotion interventions to address modifiable risk factors forACCS Team Nurse - PRD 2early morbidity and mortality of PS; including those served by both Team and those residing inGLEs/SIEs. Model appropriate interventions for direct service staff.
Design, facilitate and oversee health promotion interventions to address overall health andwellbeing of PS.
Monitor medical and psychiatric conditions of PS. Record relevant information following establishedprotocols.
Oversee MAP policies, protocols, audits and compliance for Team and associated GLEs and SIEs.Ensure that medications for PS are stored, administered, and disposed of in accordance with MAPrequirements and company policies.
Train/tutor staff to prepare for MAP certification and recertification. Teach MAP at least once peryear. Attend State mandated MAP Consultant meetings twice a year.
Monitor receipt of physical, dental and other medical documentation; work with Care Coordinationentities and care providers to obtain as needed. Provide thorough and thoughtful documentation ofPS needs and services.
When a PS is authorized for Home Health and/or Personal Care Attendant (PCA) services, obtain andreview all 485s from VNA services and obtain updates on a regular basis. Consult with VNA primarycare nurse regularly.
Advocate with medical providers for simple, effective medication regimens and for the reduction ofpoly-pharmacy.
May provide outreach services as needed to PS when they appear to disengage from ACCS services.
Promote employment services access for PS.
Perform, mentor, model evidenced-based clinical and recovery oriented interventions for PS,including Motivational Interviewing; Harm Reduction and Addiction Treatment support; Screening;Brief Intervention, Referral and Treatment (SBIRT); Housing First; Stages of Change; WellnessRecovery Action Plans (WRAP); Seeking Safety and Cognitive Behavioral interventions.
Promote engagement, safe housing, community tenure, achievement of greater self-sufficiency andsuccessful completion of service for all PS.
Provide on-call clinical coverage as scheduled.
Engage as Member of ACCS Nurse Community of Practice, facilitated by Vinfen’s Director of Nursing,to support and improve role competency and professional development.
May serve, on a limited basis, as LPHA for PS with identified high risk medical needs to facilitate CareCoordination with external parties.
Perform other related duties, as assigned. About Vinfen Why Vinfen? We are committed to you! We offer great training, great benefits, career growth and job security! Our comprehensive and generous benefits package includes: A fully funded, employer-sponsored retirement plan that requires no employee contribution as well as an employee-funded 403(b) plan First-rate Medical, Dental and Vision plans that are open all employees scheduled to work 30 hours per week or more. Plus, we offer a generous employer contribution toward the cost of medical insurance! Employer-paid Life, Accidental Death & Dismemberment and Long-Term Disability Insurance (no cost to you!) Employer-paid Short-Term Disability Insurance along with the option to purchase additional, voluntary, Short-Term disability insurance Flexible Spending Reimbursement Accounts (Health and Dependent care) Voluntary Term, Whole Life, Accident and Critical Care Insurance Generous paid time off (Employees scheduled to work 20 hours or more per week): 15 days of Vacation per year 11 Paid Holidays 10 Sick Days per year 3 Personal Days per year Educational Assistance and Remission Programs $500 Employee Referral Bonus with no annual cap! Other generous benefits including discounted YMCA memberships, access to discounted movie tickets and more! About Us: Established in 1977, Vinfen is a nonprofit, health and human services organization and a leading provider of community-based services to individuals with mental health conditions, intellectual and developmental disabilities, brain injuries, and behavioral health challenges. Our services and advocacy promote the recovery, resiliency, habilitation, and self-determination of the people we serve. Vinfen's 3,500 dedicated employees are experienced, highly-trained professionals who provide a full range of supportive living, health, educational, and clinical services in over 550 sites throughout Massachusetts and Connecticut. For more information about Vinfen, please visit www.vinfen.org/careers. My Job. My Community. My Vinfen. Vinfen is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, pregnancy, sexual orientation, gender identity, national origin, age, protected veteran status, or disability status.
Qualifications
Nursing school education and training required. Bachelor's degree preferred. Registered Nurse in Massachusetts required. Three to five years supervised practical experience preferred, including internships. Experience working with people with psychiatric disability and/or co-occurring disorders preferred. Must have access to an operational and insured vehicle and be willing to use it to transport PS. Preference given to bilingual/bicultural applicants and applicants with lived experience of psychiatric conditions. All candidates for this position must be a least 21 years of age and have held a valid US driver's license for at least 6 months and should be able to pass a CORI, driving record, employment reference, education and professional licensure check as well as a multi-state background check. Knowledge and Skills:
Strong commitment to the right and ability of people served by ACCS to live, work, have meaningfulrelationships and receive the clinical treatment, resources and supports needed to thrive in theircommunity of choice
Knowledge of Nursing treatment principles and modalities, best practices and evidence-basedpractices
Knowledge of health risks of psychiatric disability
Ability to adhere to the standards of Motivational Interviewing; Harm Reduction; Screening, BriefIntervention, Referral and Treatment (SBIRT); Housing First; Stages of Change; and CognitiveBehavioral interventions
Knowledge of PS engagement strategies
Knowledge of medical crisis prevention, crisis intervention, and risk management strategies
Knowledge of recovery-oriented, person-centered and strengths-based values and principles
Knowledge of trauma-informed and culturally competent services. Sensitivity to the cultural,religious, ethnic, disability and gender issues of PS
Knowledge of the effects of prejudice including internalized negative attitudes about oneself,discrimination, and oppression of people with psychiatric disorders, and effects of poverty.
Knowledge of human, legal, and civil rights of PS
Knowledge of medical and psychiatric emergency services and acute care systems
Knowledge of community based mental health, health care, care coordination and other servicesand resources available to PS
Skills and competence to formulate effective Treatment Plan interventions, and to trainparaprofessional staff to implement aspects of plans
Ability to collaborate effectively with other Team members to address the needs of PS in theTreatment Plan
Ability to form supportive, trusting relationships with PS
Requirements
Requires a Registered Nurse license in Massachusetts and nursing school education, with a bachelor's degree and 3-5 years of experience preferred. Candidates must be at least 21 years old with a valid driver's license and access to an insured vehicle.
bachelor degree
professional certificate
Case Management
Patient Education
Crisis Intervention
Trauma-Informed Care
Harm Reduction
Care Coordination
Clinical Documentation
Nursing Assessment
Motivational Interviewing
Health Promotion
Medication Administration Program (MAP)
Psychiatric Nursing
Benefits
Accident Insurance
Dental Insurance
Life Insurance
Paid Holidays
Vision Insurance
Long-Term Disability Insurance
Medical Insurance
Short-Term Disability Insurance
Personal Days
Accidental Death & Dismemberment Insurance
Vacation Days
403(b) Plan
Flexible Spending Reimbursement Accounts
Sick Days
Employee Referral Bonus
Discounted YMCA Memberships
Whole Life Insurance
Critical Care Insurance
Voluntary Term Life Insurance
Employer-sponsored Retirement Plan
Educational Assistance and Remission Programs
Posting details
Employment type
Full Time
Work arrangement
On Site
Experience
2-5 yrs
Salary
$89,175 - $89,175/yr
Location
Somerville, Massachusetts
Posted
Jul 13, 2026
Closes
Jul 13, 2027
Application
Employer website
Knowledge of Nursing assessment practices
Knowledge and use of different communication and learning styles
Ability to make independent judgments and decisions
Ability to work in a professional and confidential capacity
Knowledge of personal computer applications and equipment
Extensive knowledge of documentation standards and requirements Typical Requirements:
Nursing school education and training required. Bachelor’s degree preferred.
Registered Nurse in Massachusetts required.
Three to five years supervised practical experience preferred, including internships.
Experience working with people with psychiatric disability and/or co-occurring disorders preferred.
Must have access to an operational and insured vehicle and be willing to use it to transport PS.
Preference given to bilingual/bicultural applicants and applicants with lived experience of psychiatricconditions. Driving Requirements: Driving is a requirement for this position using either a Vinfen van or a personal vehicle. If using apersonal vehicle, you must possess and maintain adequate insurance as well as maintain a safe drivingrecord which is subject to annual checks. A valid driver's license must be presented at the time ofemployment. Incumbents must be at least 21 years of age, have maintained a valid US driver's licensefor at least one year, and must be able to pass a driver's screening background check. Physical Effort: Ability to stand, walk, bend, kneel, stoop, crouch, crawl, climb as this is a very physically active position.Must be able to lift at least 25 pounds using proper lifting techniques or the use of a two-person lift.Ability to operate a computer and other office equipment such as a calculator, copier, and printer.Ability to sit, reach, climb stairs, and maneuver through narrow spaces or hallways. Ability to assist PSwith tasks of daily living. Ability to remain in a stationary position 50% of the time as needed. Ability tobend, reach, file, sit, stand, and move around the facility. Ability to speak, hear, and communicate withPS, staff, and external representatives. Specific vision abilities required by this job include close vision,distance vision, color vision, peripheral vision, depth perception, and ability to adjust focus. Additional Certifications Required: CPR required within first two weeks of hire Pay Range USD $89,175.00 - USD $89,175.00 /Yr.
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