Posted in Other 30+ days ago.
Location: Boston, Massachusetts
Why This Role is Important to Us
Commonwealth Care Alliance's (CCA) Care Partner is primarily responsible for providing longitudinal care coordination and care management to a dedicated panel of dually-eligible CCA members, a group of individuals with significant medical, behavioral, and social complexities that require intensive clinical support. The Care Partner provides, care management, and care coordination to a defined panel of CCA members needs through telephonic interactions. The panel of members will be comprised of individuals with significant medical, behavioral, and social complexities that require intensive clinical support (in addition to that provided by the member's primary care provider) that create barriers to fully and successfully accessing the health care system. The Care Partner is the primary clinical and care management provider for their panel of members. Responsibilities include: comprehensive care management, chronic disease management, preventative care and wellness, liaison with relevant other providers around behavioral health and long term service and support needs, and the provision (with support) of end of life/palliative care, as needed. Role also includes a compendium of care management/ care coordination functions encompassing the development and implementation of the member-centered individualized care plan along with oversight in the authorization of appropriate services and supplies.
What We're Looking For
Minimum Education: Diploma in Nursing or an ADN
Preferred Education: Bachelors in Nursing
Minimum 2 years meaningful clinical experience in primary care or care management including telephonic based setting, home health or acute care case management.
Past experience caring for patients/members with complex medical, behavioral health, and social needs strongly preferred.
Must be licensed in Massachusetts
Past experience caring for patients/members with complex medical, behavioral health, and social needs strongly preferred. - Ability to use SBAR Communication
- Ability to utilize an Electronic Medical Record
- Ability to use on-line training platforms - Ability to review welcome packets and obtain consent forms and attach them to EMR - Demonstrated understanding of when an updated MDS is needed
- Ability to complete and update a Care Plan that meets CCA requirements
- Demonstrated understanding of LTSS - Demonstrated understanding of how to use CDSTs when ordering services - Ability to create referrals and authorize services within appropriate time frames
- Ability to lead a family/team meeting for the purposes of discharge planning
- Demonstrated knowledge and ability to use screening/ assessment tools (e.g., Fall risk assessment, mini cog assessment, nutritional assessment, PHQ 2, PHQ 9, BH)
- Ability to conduct Crisis assessments over the phone and deploy assistance as needed
- Demonstrated ability of how to locate current guidelines for recommended screening tests and immunizations - Demonstrated understanding of Referral to Specialists -
Preferred:
- Demonstrated understanding of, and can apply, member stratification
- Demonstrated understanding of how Minimum Data Set (MDS) supports stratification
- English required, bilingual preferred
- Facilitates preventative and basic primary care to members, as needed, per CCA standard operating procedures, commonly accepted medical guidelines, and appropriate scope of practice.
- Provides regularly scheduled telephonic calls to support the management of chronic disease or end of life/ - Assist the member with understanding their CCA Health Benefit package
- Tracks MDS due dates and assist in scheduling MDS assessments
- Adheres to appropriate and complete documentation practices, including: history of present illness, adjustment or maintenance of an established treatment plan, and consistent follow up of the plan as evidenced in the documentation.
- Performs episodic urgent medical/ behavioral health telephone calls and facilitates such visits are conducted in-person for members on panel to ensure that timely and appropriate medical care in order to avoid emergency department visit or hospitalization.
- Ensures that post-discharge visits are performed for panel members within 48-hours of discharge from an acute care facility, Psychiatric or a skilled nursing facility to decrease risk of readmission.
- Performs detailed medication reconciliation, as appropriate, based on licensure - Ensures appropriate LTSS are in place and collaborates with GSSC/LTSC on members' needs
- Review the Quality Gap Report weekly and addresses clinical quality gaps (e.g., HEDIS), collaborating with the community APC and RNs on the team, along with the member's PCP
- Liaises with CCA interdisciplinary site team to ensure comprehensive member needs are consistently met - Manages panel-wide and member-specific utilization trends - Liaises with CCA and community-based PCPs/specialists
- Ensures appropriate documentation of visits and activities within CCA's central enrollee record and within 48 hours of visits
- Participates in weekly Interprofessional Team Meetings - Collaborates with the Transitions of Care Team on all medical and psychiatric admissions to assist in discharge planning
- Adjusts the member-centered plan of care as necessary based on a significant change in condition. A change in condition is an event (hospitalization, acute illness, etc.) which results in either a short- or long-term change in need (examples include adding in Palliative care, increasing personal care hours short term post hospitalization, or purchasing high cost durable medical equipment for a non-reversible functional change)
- Utilizes Clinical Decision Support Tools, team meetings, and consultation with CCA specialists, authorizes proposed equipment and/or services for the implementation of the individualized plan of care and collaborates with CCA Utilization Management staff to ensure appropriate medical necessity criteria are met. Participates in utilization and case review as necessary
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