RN, Care Partner (Telephonic)
Company: Commonwealth Care Alliance
Posted on: November 10, 2019
WHY THIS ROLE MATTERS:
Commonwealth Care Alliance s (CCA) Telephonic 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
The Telephonic 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. Telephonic Care Partners work remotely from their
* 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
* Tracks MDS due dates and assist in scheduling MDS
* 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
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
* 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 Inter-Professional 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.
YOU LL BE A GOOD FIT IF:
* Associate s Degree in Nursing, Bachelor s Degree preferred.
* Registered Nurse with licensure in good standing in
* 2-4 years 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.
* Willing to come to the local CCA office for various meetings.
* Willing to attend meetings across the state of 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 , RN, Care Partner (Telephonic), Healthcare , Springfield, Massachusetts
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