Community Weekend Registered Nurse
Company: Commonwealth Care Alliance
Posted on: September 6, 2020
COMMUNITY WEEKEND REGISTERED NURSE
Actual Work Location
101 Wason, Springfield, MA
WHY THIS ROLE IS IMPORTANT TO US
Commonwealth Care Alliance s (CCA) Community Weekend Registered
Nurse (RN) ensures the highest quality, primary and community based
skilled care is provided to CCA members, a group of individuals
with significant medical, behavioral, and social complexities that
require intensive clinical support, within the context of a member
centric individualized plan of care.
The Community Weekend RN has the opportunity to use evidence-based
practice, clinical skills, education, and training to influence the
clinical outcomes of CCA s membership by impacting acute care
utilization, ensuring optimal treatment for chronic disease
management, closing of quality gaps, LTSS and home based community
services utilization, , goals of care conversations, advance care
planning, providing skilled nursing services that allow for optimal
self-management, and supporting palliative and end of life
The Community Weekend RN will collaborate with the member s network
PCP, providers, and specialists in the development and
implementation of clinical plans of care.
As an integral part of the Care Team the Community Weekend RN will
engage in regular assessments for MDS assessments, LTSS assessments
and skilled care, perform post discharge assessments on members
following discharge from a facility, and conduct acute visits to
ensure that members Plan of Care is comprehensive and addresses
significant medical, behavioral, and social needs.
This position requires in person visits to members in their homes
or in the community and will support members across various
location in Massachusetts.
Friday: 8:30 5:00
Saturday: 8:30 am 9:00 pm
Sunday: 8:30 am 9:00 pm
WHAT YOU\'LL BE DOING
THIS POSITION WILL SUPPORT THE SPRINGFIELD, MA AREA
* Performs episodic urgent medical/ behavioral health visits to
ensure that members are given timely and appropriate medical care
to avoid emergency room or hospitalization.
* Conducts a variety of assessments within their scope of practice;
including but not limited to MDS and LTSS assessments.
* Facilitates and/or delivers preventative care to members
according to the guidelines deemed appropriate by CCA.
* To decrease risk of readmission, performs post discharge visits
on members within 48-hours of discharge from either an acute care
facility or a skilled nursing facility; performs detailed
medication reconciliation, and ensures appropriate LTSS are in
* Collaborates with CCA Care Partner and community based PCPs/
Specialists, as needed.
* Collaborates with CCA interdisciplinary site team to ensure
comprehensive member needs are consistently met
* With a signed Provider s order, performs Intermittent Skilled
Care as necessary (e.g., wound care, medication management, routine
and chronic disease assessment and other skilled needs).
* With a signed Provider s order, performs palliative care skilled
* Provides education to member and family, as appropriate
* Assesses quality gap reports at each face to face visit;
collaborate with care team and PCP to close these gaps
* Assesses MDS needs prior to every visit and complete MDS
assessment if due within 60 days
* Completes fall log as appropriate
* Attends weekly Team Meetings and participates in case
* Attends weekly 1:1 supervision with manager
* Documents all activities and results using an Electronic Medical
Record, in an effective manner while strictly adhering to CCA
policies and procedures.
* Utilizing and depending on CCA internal resources, ensures that
the plan of care is implemented in a timely manner.
* Adjusts the member centered plan of care as necessary based on a
significant change in condition
* Identifies members who require escalation to the APC or MD for
WHAT WE\'RE LOOKING FOR
* Associate s Degree in nursing required, Bachelor s Degree in
* Experience in managed care/insurance preferred
* Meaningful clinical experience in care management preferred
* 3+ years experience as an RN in home health care or case
* 2+ years caring for patients/ members with complex medical,
behavioral health, and social needs
* 1+ years as CCA Care Partner (or prior similar role) strongly
* RN licensure in good standing in the Commonwealth of
* Current CPR or Basic Life Support (BLS) Certification
* Demonstrate an understanding of the benefits of CCA s product
* Palliative care skills/interventions
* Chronic disease management and Behavioral Health experience
* Phlebotomy skill and knowledge required
* Wound care experience/knowledge (simple and complex)
* Able to work independently in the field
* Able to organize, manage and prioritize clinical needs
* Provide healthcare education to members
* Communicate with on-call MDs and on-call PCPs
* Able to work in a fast-paced environment and able to change
priorities as needed
* Pain management knowledge and pain education
* Able to utilize Electronic Medical Records (EMR)
* Is able to use SBAR communication
* Experience with technology (outlook, word)
* English required, bilingual preferred (Spanish, Haitian-Creole,
We offer Excellent benefits, including:
* Medical, dental and vision plans with low employee
* A generous paid time off program
* 403(b) with company match
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 , Community Weekend Registered Nurse, Healthcare , Springfield, Massachusetts
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