Commonwealth Care Alliance Community Registered Nurse - Roxbury - Hybrid in Charlestown, Massachusetts
Why This Role is Important to Us
The Community Registered Nurse ensures that a defined panel of enrolled individuals receives the highest quality, primary and community based skilled care within the context of a member centric individualized plan of care. The Community Registered Nurse 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, 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 care. The Community Primary Nurse 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 Registered Nurse 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.
The Community Registered Nurse is supported by a fully staffed interprofessional care team that has, at its core, a Care Partner who is accountable for all aspects of care management and care coordination. The Community Registered Nurse collaborates with the entire care team, and keeps the Care Partner well informed on members', providing critical clinical information that helps drive the overall ICP. The Community Registered Nurse will make adjustments to the ICP as indicated, identifying gaps and, in concert with the Care Partner, will leverage covered benefits to ensure that the right mix of services are in place to meet the member's unique needs.
This position requires in person visits to members in their homes and will support members across various locations
The Community RN reports to the team Clinical Manager
What You'll Be Doing
This position covers Back Bay, Beacon Hill, Charlestown, China Town, Downtown, Kenmore, North End, Roxbury, South End, and South Boston
Performs episodic urgent medicalvisits to ensure that members are given timely and appropriate medical care in order to avoid emergency room or hospitalization.
Conducts a variety of assessments within their scope of practice; including but not limited to MDS ( in Massachusetts), and LTSS assessments.
Facilitates and/or delivers preventative care to members according to the guidelines deemed appropriate by CCA.
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).
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
Performs joint visits with other care team members as appropriate to address complex care needs
Attends Interprofessional Team Meetings
Participates in RCA as appropriate
Documents 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.
Participates in weekend and holiday rotation which may include working Saturday, Sunday or a weekday holiday up to two times a year.
Provide clinical care to members via telehealth technologies (video, chat, etc.) for a clinically appropriate clinical care and care management services.
What We're Looking For
Associate's Degree or Diploma in nursing required; Bachelor's Degree in nursing preferred.
Meaningful clinical experience in primary care or care management, including:
5+ years' experience as Registered Nurse in a high touch clinical environment or home care; OR 2+ years caring for patients/members with complex medical, behavioral health, and social needs
Registered Nurse with licensure in good standing in the state assigned to work
Certified in Basic Life Support for Healthcare Providers.
Current CPR or Basic Life Support (BLS)
Demonstrate an understanding of the benefits of CCA's product lines
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
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 assessment is needed
Is able to complete a comprehensive 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 complete and lock all required notes and telephone encounters within 48 hours
Participates in case discussions
Ability to conduct Crisis assessments over the phone and deploy assistance as needed
Able to lead a family/team meeting for the purposes of discharge planning
Obtains/documents a comprehensive history
Demonstrates knowledge and ability to use screening/ assessment tools to Fall risk assessment
Assist with Advanced Care Planning, including establishing goals of care with member
Willing to learn and utilize telehealth technologies (video, chat, etc.), when appropriate, for a variety of clinical care and care management services.
English required, Bilingual preferred
Commonwealth Care Alliance
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