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Commonwealth Care Alliance Community Registered Nurse in Charlestown, Massachusetts

The Community Registered Nurse ensures that a defined panel of dually eligible individuals receives the highest quality, primary and community based skilled care within the context of a member centric individualized plan of care. The Community Primary 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 Registered 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 Primary 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.

Engagement by the Primary Registered Nurse can occur in two different ways:

Short term, episodic delivery of skilled nursing services can be deployed for members who have a triggering event (hospitalization, fall), including identification through CCA’s propriety predictive analytics, suggesting that a member is at rising risk and would benefit from increased skilled nursing engagement. Skilled Nursing support of longitudinal enhanced primary care engagement is indicated for members who have needs that require a heightened level of ongoing in person clinical engagement. (Frail elders, cognitive deficits, dementia)

The Community Primary Registered Nurse is supported by a fully staffed interprofessional care team that has, at its core, a Telephonic Care Partner who is accountable for all aspects of care management and care coordination. The Community Primary Registered Nurse collaborates with the entire care team, and keeps the Telephonic Care Partner well informed on members’, providing critical clinical information that helps drive the overall ICP. The Community Primary Care Registered Nurse will make adjustments to the ICP as indicated, identifying gaps and, in concert with the Telephonic Care Partner, will leverage covered benefits to ensure that the right mix of LTSS and DME are in place to meet the member’s unique needs.

• The role also includes providing input to members’ care teams on, including updating the member centered care plan and identification of the need for LTSS services.

• This position requires in person visits to members in their homes and will support members across various locations in Massachusetts.

• The Community RN reports to the team Clinical Manager

• Performs episodic urgent medical/ behavioral health visits 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 and LTSS assessments.

• Facilitates and/or delivers preventative care to members according to the guidelines deemed appropriate by CCA.

• In order 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 place.

• 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, can perform 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

• Assess quality gap reports at each face to face visit; collaborate with care team and PCP to close these gaps

• Assess MDS needs prior to every visit and complete MDS assessment if due within 60 days

• Perform joint visits with other care team members as appropriate to address complex care needs

• Complete fall log as appropriate

• Attend weekly Interprofessional Team Meetings

• Participate in RCA as appropriate

• 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.

• Participates in weekend and holiday rotation which may include working Saturday, Sunday or a weekday holiday up to two times a year.

• Identifies members who require escalation to the APC or MD for further evaluation

Must be willing and able to travel to member’s homes in addition to working in an office environment occasionally

Valid driver’s license with no restrictions. Ability to be active and mobile across Massachusetts

Minimum Associate’s Degree in nursing or Diploma in Nursing required, Bachelor’s Degree in nursing preferred

Meaningful clinical experience in primary care or care management, including:

• Minimum 5 years’ experience as Registered Nurse in a high touch clinical environment or home care; OR

• Minimum 2 years caring for patients/members with complex medical, behavioral health, and social needs

Registered Nurse with licensure in good standing in Massachusetts.

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 MDS is needed

• Is able to complete a comprehensive MDS 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

• Returns all non-urgent calls within 1 day and urgent calls as soon as possible

• Performs a post-discharge visit within 48 hours of discharge

• 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 members

• English required, bilingual preferred

Telephonic Care Partners work remotely from their home. Must have strong internet signal.

Must be able to come to the local CCA office in the event Shortel is unavailable

May require meetings across the state of Massachusetts

We offer excellent benefits, including:

  • Medical, dental and vision plans with low employee contributions

  • A generous paid time off program

  • 403(b) with company match

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ID: 2020-3219

External Company Name: Commonwealth Care Alliance, Inc.

External Company URL: http://www.commonwealthcarealliance.org/

Actual Work Location: Charlestown, MA

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