Telephonic RN Care Partner
Company: Commonwealth Care Alliance
Posted on: March 25, 2020
TELEPHONIC RN CARE PARTNER
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
* Monitors and, as applicable, addresses clinical quality gaps
* 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
* 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
* 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
* 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
A generous paid time off program
403(b) with company match
Loan Forgiveness Program
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
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