Telephonic RN Care Partner

Company: Commonwealth Care Alliance
Location: Springfield
Posted on: March 25, 2020

Job Description:

*

TELEPHONIC RN CARE PARTNER

Job ID

2020-3012

Category

Clinical (Community)

Type

Regular Full-Time

Actual Work Location

101 Wason, Springfield, MA

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 RN 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 RN 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 Telephonic 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.



This is a full time position working remotely and will require travel to the office for meetings and trainings. The first 90 days will be on site in the office for orientation and training.



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.

WHAT YOU\'LL BE DOING

* Facilitates preventative and basic interventive (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/palliative care.

* Adheres to appropriate and complete documentation practices, including: history of present illness, ordering of appropriate studies and tests, 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 (or ensures 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 either an acute care facility or a skilled nursing facility to decrease risk of readmission; performs detailed medication reconciliation, adjusts medications as indicated, and ensures appropriate LTSS are in place.

* Monitors and, as applicable, addresses clinical quality gaps (e.g., HEDIS)

* Liaises with CCA interdisciplinary site team to ensure comprehensive member needs are consistently met (e.g., behavioral health, health outreach, chronic disease management, etc.)

* 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 the record of partners as indicated.

* Within a defined (dependent on the acuity of the member s needs) period of time post assignment, develops a member-centered care plan which is inclusive of appropriate long term support services and optimizes available resources to improve or maintain health and functional independence in the community.

* On a semi annual or annual basis, reviews and updates the member-centered care plan and adjusts as indicated. Reviews care plan with the member and ensures that it is available to the member.

* 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 Authorizations Unit staff to ensure appropriate medical necessity criteria are met. Participates in utilization and case review as necessary.

* Utilizes and depending on CCA internal resources, ensures that the member-centered plan of care is implemented in a timely manner.

* Performs defined functions of the authorization process as indicated by CCA policies and procedures.

WHAT WE\'RE LOOKING FOR

* Associate's degree in Nursing, Bachelor's degree preferred

* 2+ years of meaningful clinical experience in primary care or care management including telephonic based setting, home health or acute care case management.

* Experience caring for patients/members with complex medical, behavioral health, and social needs strongly preferred.

* RN licensure must be in Massachusetts

* English required, bilingual preferred



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

Educational Assistance/Reimbursement



keywords: RN, registered nurse, master's degree, healthcare, case management, case manager, care coordinator, care coordination, clincial, clinician, community health, social services, complex, medical, behavioral, bilingual, telephonic, managed care, telecommute, remote, Springfield, MA, Massachusetts

Commonwealth Care Alliance is an equal opportunity employer. Applicants are considered for positions without regard to veteran status, uniformed service member status, race, color, religion, sex, national origin, age, physical or mental disability, genetic information or any other category protected by applicable federal, state or local laws.

Keywords: Commonwealth Care Alliance, Springfield , Telephonic RN Care Partner, Healthcare , Springfield, Massachusetts