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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

Qualifications:

  • 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

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