Commonwealth Care Alliance Job Details: NP Care Partner in Lawrence, Massachusetts

Job Details: NP Care Partner

On-Line Application

  • Vacancy NoVN2392

Posting TitleNP Care Partner

Location CityLawrence

Language Requirement

Job Description


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) Care Partner Team is primarily responsible for providing longitudinal care coordination, care management, and/or care delivery to a dedicated panel of dually-eligible CCA members, a group of individuals with significant medical, behavioral, and social complexities that require intensive clinical support.

This position will support the North Team to include but not limited to Lowell, Billerica, Haverhill, Dracut also attend clinical meetings in our Lawrence, MA office

The NP, Care Partner (Mobile) will provide ongoing chronic disease management, urgent visits, promote preventative care and wellness, and provide end of life/palliative care. Role also includes a compendium of care management/ care coordination functions encompassing the development and implementation of the member centric individualized care plan along with authorization of appropriate durable medical equipment and services.

Key Responsibilities:

• Within a defined time period post assignment, perform a comprehensive annual assessment taking a detailed history, performing a physical examination, and documenting appropriate diagnosis with a plan to address unmet needs associated with the diagnosis. The onboarding Annual Comprehensive Assessment also ensure capturing appropriate High Risk Codes under CMS guidelines

• On an annual basis, conduct an Annual Comprehensive Assessments on assigned panel members, taking a detailed history, performing a physical examination, and documenting appropriate diagnosis in order to ensure capture of high risk codes under CMS guidelines.

• Facilitate, and/or deliver 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, co morbidities, etc. Identify and initiate a plan to resolve areas of opportunity to meet quality metrics.

• Provide 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.

• Perform episodic urgent medical/ behavioral health visits to ensure that panel members are given timely and appropriate medical care in order to avoid emergency room or hospitalization. Visit includes a detailed history of present illness, review of systems, physical exam, ordering of appropriate studies and tests, identification of a definitive diagnosis, development of a treatment plan, and evidence of follow up through timely documentation.

• In order to decrease risk of readmission, perform post discharge visits on panel members within 48-hours of discharge from either an acute care facility or a skilled nursing facility; perform detailed medication reconciliation, adjust medications as indicated, and ensure appropriate LTSS are in place. Visit will include history of causes for recent admission, review of systems, physical exam, ordering of appropriate diagnostic tests or studies, determination of a diagnosis, development of a treatment plan, and a member centric “action plan” which will provide education and guidance encouraging self-management with future episodes.

• Liaise with CCA and community based PCPs/ Specialists, as needed

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

• Ensure appropriate documentation of visits and activities within CCA’s central enrollee record and within the record of partners as indicated. This is accomplished through either documenting oneself in multiple systems, or utilizing internal resources that will facilitate documentation.

• Within a defined (dependent on the acuity of the member’s needs) period of time post assignment, develop a member centric care plan which is inclusive of appropriate long term support services and optimizes available resources to improve or maintain health and functional independence in the community.

• On a semiannual or annual basis, review and update the member centric care plan and adjust as indicated. Review care plan with the member and ensure that it is available to the member.

• Adjust the member centric 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 Clinical Decision Support Tools, team meetings, and consultation with CCA specialists, authorize proposed equipment and/or services for the implementation of the individualized plan of care. Participate in utilization and case review as necessary.

• Utilizing and depending on CCA internal resources, ensure that the plan of care is implemented in a timely manner.

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

• Conduct annual/6 month MDS assessments and annual comprehensive assessments for panel members based on program. (Every 6 months for SCO, annually for One Care)

• Perform MDS assessments when rating category needs to be adjusted

• Act as a mentor to other team members to help promote/foster accountability, reliability, and independence among the other team members

• Provide consultation and support to other members of CCA Care Team

• Participate 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

• Actively participate in the evaluation of own performance and progress

• Participate in activities and education to maintain and advance competency

Minimum Education Required Bachelor's Degree

Preferred Educational Experience Master’s Degree

Minimum Years’ Experience required 3 years

Minimum 2 years of hands on clinical experience, defined as:

• No NP but with substantial (5 or more years as an RN in a high-touch clinical environment or home care)

• 3 years of NP experience (preferably in primary care)

Knowledge, Skills and Abilities • Board Certified Nurse Practitioner or Physician Assistant with licensure in good standing in the Commonwealth of Massachusetts.

• Will be required to pass CCA’s credentialing process.

• Current Mass Controlled Substances License required

• Current DEA Controlled Substances License required

• Current CPR or Basic Life Support (BLS) Certification

We recognize that food allergies can cause serious, life-threatening conditions for people. To keep all our employees safe, CCA’s offices are nut-free. If you have questions about the restrictions in the office you applied for, please ask your recruiter.

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.