Commonwealth Care Alliance Job Details: Nurse Practicioner, RRT in Charlestown, Massachusetts

Job Details: Nurse Practicioner, RRT

On-Line Application

  • Vacancy NoVN2086

Posting TitleNurse Practicioner, RRT

Location CityCharlestown

Language RequirementSpanish Preferred

Job Description

ORGANIZATION OVERVIEW:

Commonwealth Care Alliance is a rapidly growing nonprofit organization providing integrated health care and social support services to people with complex medical needs. Our patients are seniors and persons with disabilities covered under Medicaid or both Medicaid and Medicare. Our innovative care model is nationally recognized for its effectiveness in improving health outcomes for these vulnerable populations.

Our unique care model is empowering for our employees as well as our members. Whether you are a clinical or administrative professional, all of us at Commonwealth Care Alliance receive the satisfaction of knowing our work truly makes a difference. We enjoy a company culture of passionate advocacy in a supportive work environment with opportunities for growth and learning, competitive salaries, and a generous and comprehensive benefit package.

Commonwealth Care Alliance’s (CCA) Ready Resource Team (RRT) is primarily responsible for providing

short-term in-person episodic care and care management to a flexible panel of dually-eligible CCA members, a

group of individuals with significant medical, behavioral, and social complexities that require intensive clinical

support.

TheAdvanced Practice Clinician (NP or PA) on the Ready Resource Team (RRT)provides short term, episodic

enhanced primary care to a flexible panel of dually-eligible members from both the SCO and One Care

population. The need for the RRT APC is triggered by an acute event or significant change in condition of a

member which necessitates close, short term follow up by an Advanced Practice Clinician. The population is

made up of members across all CCA models, including those served by telephonic and mobile Care Partners

from various disciplines (RN, BHS, HOW.) The RRT APC also serves as a clinical content and patient face to face

engagement expert to support mobile and telephonic teams in palliative/ end of life care, chronic disease

management, behavioral health prescribing, pain management, and other urgent issues. The RRT APC will

provide short term, episodic chronic disease management, make urgent visits, promote preventative care and

wellness, and provide end of life/palliative care. The role also includes performing a discrete set of care

management / care coordination functions, including the adjustment of the member centric care plan and authorization

of appropriate

durable medical equipment and services.

Key Responsibilities:

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

Clinical Leadership. Guidelines may vary based on the individual make-up of the member and is based on age,

comorbidities, etc.

• Identifies and initiates a plan to resolve areas of opportunity to meet quality metrics.

• Provides limited regularly scheduled follow up visits for the management of chronic disease or end of

life/palliative care. Visits are inclusive of a history of present illness, review of systems, physical exam, ordering

of appropriate studies and tests, identification of a definitive diagnosis, adjustment or maintenance of an

established treatment plan, and consistent follow up of the plan as evidenced in the documentation.

• 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, adjust medications as indicated, and ensure appropriate LTSS are in place.

• Liaises with CCA Care Partner and community based PCPs/ Specialists, as needed

• Provides Intermittent Skilled Care as necessary (e.g., wound care,)

• Documents all activities and results using an Electronic Medical Record, in an effective manner while strictly

adhering to CCA policies and procedures

• 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) Utilizing and depending

on CCA internal resources, ensures that the plan of care is implemented in a timely

manner.

• Performs defined functions of the authorization process as indicated by CCA policies and procedures.

• Palliative care consultations and skilled interventions

• Participates in “weekend schedule” rotation which includes working Saturday, Sunday, and 2 weekdays.

Estimated at 6-8 times per year

Secondary Responsibilities:

Acts as a mentor to other team members to help promote/foster accountability, reliability, and independence

among the other team members

• Provides consultation and support to CCA team

• Participates in Team Case Review

• Maintains appropriate written and oral communication on a timely basis completing documentation within 24

hours of activity, and returning non-urgent calls within 48 hours

• Conducts educational and training activities that promote appropriate, safe, effective patient care

• Actively participates in the evaluation of own performance and progress

• Participates in activities and education to maintain and advance competency

• Participates in CCA quality improvement efforts

• Assists CCA management and leadership with the development, refinement and enhancement of clinical

programs, initiatives, processes, policies, workflows, and projects

• Participates in committees and workgroups that promote clinical excellence and help to advance CCAs

mission and business objectives

• Maintains confidentiality of patient and employee information

• Complies with organization’s policy and procedures

• Advocates for members in a culturally competent manner.

• Seeks maximum member and family participation to promote independence

Minimum Education Required Bachelor's Degree in Nursing

Preferred Educational Experience Master’s Degree in Nursing

Minimum Years’ Experience Required 3 years

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

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

• 3 years’ experience as an NP in primary care or care management; AND

• 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 preferred

Board Certified NP or Physician Assistant with licensure in good standing in theCommonwealth of Massachusetts.

Please note employment with CCA is contingent upon acceptable professional references, a background check (including Mass CORI, employment, education, criminal check, and driving record, (if applicable)), an OIG Report and verification of a valid MA/RN license (if applicable).

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.

CCA is committed to protecting the health of our workforce and our members, and we encourage flu vaccination in accordance with CDC recommendations. Individuals working in clinical care areas or in direct contact with members must provide documentation of flu vaccination, or wear a mask during flu season whenever engaged in member-facing activities.