Posted in Other 11 days ago.
Location: Springfield, Massachusetts
Why This Role is Important to Us
At Commonwealth Care Alliance (CCA), our vision is to lead the way in transforming the nation's healthcare for individuals with the most significant needs. If being part of a team and working on combined solutions for patients matters to you...keep reading. We may have something to talk about.
The Community Advanced Practice Clinician ensures that a defined panel of dually eligible individuals receives the highest quality, primary care within the context of a member centric individualized plan of care. The Community APC has the opportunity to use evidence, clinical skills, education, and training to influence the clinical outcomes of CCA's members by impacting acute care utilization, ensuring optimal treatment for chronic disease management, closing of quality gaps, participation in Annual/Geriatric Assessments, goals of care conversations, advance care planning, and delivering palliative and end of life care. The Community APC will maintain close contact and collaboration with the member's network PCP, providers, and specialists in the development and implementation of clinical plans of care.
As an integral part of an Interprofessional Care Team and based on the fluctuating needs of the defined panel of members, the Community Advanced Practice Clinician will engage in regular assessments, visits at regularly scheduled intervals, and conduct acute visits to ensure that members' Plan of Care is comprehensive and addresses significant medical, behavioral, and social needs.
Engagement by the APC can occur in two different ways.
Episodic care is triggered by an acute event or significant change in condition of a member which necessitates close, short term follow up by an Advanced Practice Clinician. Longitudinal enhanced primary care is delivered to members who are medically complex, with limitations that create a barrier for traditional in office visits.
The role also includes performing a discrete set of care management/care coordination functions, including the adjustment of the member centric care plan and authorization of appropriate durable medical equipment and services.
At CCA, your role matters. You'll be joining an organization that is mission driven, believes in internal mobility, has excellent benefits (see below) and embraces innovation when it comes to serving our patients.
Master's Degree in Nursing, Doctor of Nursing Practice or a degree in Physician Assistant Studies
Board Certified NP or Physician Assistant with licensure in good standing in the Commonwealth of Massachusetts.
Meaningful clinical experience in primary care or care management, including: * 5+ years' experience as Registered Nurse or EMT-P in a high touch clinical environment or home care; OR * 3+ years' experience as an NP or PA in primary care or care management; at least * 2+ years caring for patients/ members with complex medical, behavioral health, and social needs
Will be required to pass CCA's credentialing process
Current Mass Controlled Substances License required
Current DEA Controlled Substances License required
Current CPR or Basic Life Support (BLS) Certification Required
Is able to conduct and document a Pain Assessment
Is able to use SBAR Communication
Is able to conduct and document Home Safety Evaluation
Is able to provide Wound Care (simple & complex)
Is able to utilize an Electronic Medical Record and Care Management Platform
Is able to use on-line training platforms
Demonstrates an understanding of the Model of Care
Demonstrates an understanding of the benefits of each program
Is able to review welcome packets and obtain consent forms and attach them to EMR
Demonstrates an understanding of when an updated MDS is needed
Is able to complete a comprehensive MDS Assessment
Is able to complete and update a Care Plan that meets CCA requirements
Demonstrates an understanding of LTSS
Demonstrates an understanding of how to use CDSTs when ordering services
Is able to create referrals and authorize services within appropriate time frames
Is able to complete and lock all required notes and telephone encounters within 48 hours
Participates in case discussions
Able to lead a family/team meeting for the purposes of discharge planning
Returns all non-urgent calls within 2 days and urgent calls as required
Performs a post-discharge visit within 48 hours of discharge
Obtains/documents a comprehensive history
Demonstrates knowledge and ability to use screening/ assessment tools to Fall risk assessment, Mini cog assessment, Nutritional assessment, PHQ 2, PHQ 9
Able to perform venipuncture
Demonstrates ability of how to locate current guidelines for recommended screening tests and immunizations
Is able to conduct and document an Annual Comprehensive Exam
Is able to formulate Diagnosis/ Differential Diagnosis
Demonstrates an ability to prescribe medications
Demonstrates an ability to order diagnostic testing
Does this sound like you? If you're interested in this opportunity, please apply today. The process takes 10-15 minutes. We offer excellent benefits, including:
Medical, dental and vision plans with low employee contributions
A generous paid time off program
403(b) with company match
Loan Forgiveness Program
keywords: RN, registered nurse, NP, nurse practitioner, PA, physician assistant, clinical, bachelor's, master's, MSN, integrated care, medical, behavioral, complex care, care management, care delivery, case management, community, home health, hospice, Medicare, Medicaid, MassHealth, complex, medical, behavioral, bilingual, telephonic, community, home health, managed care, non profit, not for profit, Springfield, Massachusetts, MA
* Performs both urgent and routine visits on members to evaluate condition and add to the plan of care
* Orders appropriate medical testing to aid in the diagnosis and medical management of acute and chronic diseases
* Leverages CCA clinical resources (InstED) to avoid emergency room visits and inpatient admissions
* Evaluate test results, appropriately treat member illness and communication/collaborate plan with PCP
* Facilitates and/or delivers preventative care to members according the guidelines deemed appropriate by CCA
* Engages in appropriate clinical collaboration with clinical experts, including the member's PCP, CCA Medical Directors, and other CCA Advanced Practice Clinicians. Clinical Leadership. Guidelines may vary based on the individual make-up of the member and is based on age, comorbidities, etc.
* If appropriate, provide medical and psychiatric bridge prescribing abilities for members in transition between providers
* Evaluate member's HEDIS measure needs, write orders as appropriate to manage these gaps and follow up with PCP on results Assist with Advanced Care Planning, including establishing goals of care with members and obtaining MOLST forms
* Provides limited regularly scheduled follow up visits for the management of chronic disease. Visits are inclusive of a history of present illness, review of systems, physical exam, ordering of appropriate studies and tests, identification of a definitive diagnosis, adjustment or maintenance of an established treatment plan, and consistent follow up of the plan as evidenced in the documentation
* In order to decrease risk of readmission, performs post discharge visits on member members within 48-hours of discharge from either an acute care facility or a skilled nursing facility; performs detailed medication reconciliation, adjust medications as indicated, and ensure appropriate LTSS are in place
* Liaises with CCA Care Partner and community based PCPs/ Specialists, as needed
* Provides Intermittent Skilled Care as necessary (e.g., wound care,)
* Documents all activities and results using an Electronic Medical Record, in an effective manner while strictly
* Complete MDS assessments
* Complete Annual/Geriatric Comprehensive Assessments to ensure all members have had an annual physical exam
* Complete medication reconciliation with every member visit. Attend weekly Interprofessional Team Meetings
* Participate in Root Cause Analysis (RCA) as appropriate
* At each visit, provide member education, assess vital signs and complete medication reconciliation.
* Formulating an action/ treatment plan based on scientific rationale, evidence -based standards of care and practice guidelines that demonstrate critical thinking, diagnostic reasoning and knowledge of the pathophysiology of acute and chronic disease and conditions.
* Monitoring the response to the action / treatment plan with appropriate and timely follow up, evaluation and initiating necessary changes in the action / treatment plan. adhering to CCA policies and procedures.
* 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)
* Utilizing and depending on CCA internal resources, ensures that the plan of care is implemented in a timely manner.
* Collaborate in evaluating member's service plan and authorization to inform Telephonic Care Partner and allow for appropriate service utilization for members.
* Ability to document clearly and comprehensively. 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) Utilizing and depending on CCA internal resources, ensures that the plan of care is implemented in a timely manner.
* Collaborate in evaluating member's service plan and authorization to inform Telephonic Care Partner and allow for appropriate service utilization for members
* Participates in "weekend schedule" rotation which includes working Saturday, Sunday, and 2 weekdays. Estimated at 6-8 times per year.
* Ability to document clearly and comprehensively. Acts as a mentor to other team members to help promote/foster accountability, reliability, and independence among the other team members * Provides consultation and support to CCA team
* Participates in Team Case Review
* Maintains appropriate written and oral communication on a timely basis completing documentation within 24 hours of activity and returning non-urgent calls within 48 hours.
* Conducts educational and training activities that promote appropriate, safe, effective patient care
* Actively participates in the evaluation of own performance and progress.
* Participates in activities and education to maintain and advance competency
* Participates in CCA quality improvement efforts
* Assists CCA management and leadership with the development, refinement and enhancement of clinical programs, initiatives, processes, policies, workflows, and projects
* Participates in committees and workgroups that promote clinical excellence and help to advance CCAs mission and business objectives
* Maintains confidentiality of patient and employee information
* Complies with organization's policy and procedures
* Advocates for members in a culturally competent manner.
* Seeks maximum member and family participation to promote independence
Must be willing and able to travel to member's homes in addition to working in an office environment occasionally.
Must be willing and able to attend meetings at the at the office, with other travel possible.
Valid driver's license with no restrictions.