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Care Partner

Commonwealth Care Alliance

This is a Contract position in Lawrence, MA posted September 15, 2020.

At Commonwealth Care Alliance (CCA), our vision is to lead the way in transforming the nation’s healthcare for individuals with the most significant needs.

If being part of a team and working on combined solutions for member’s matters to you…keep reading.

We may have something to talk about 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.

As an integral part of our Model of Care the Telephonic Care Partner provides longitudinal enhanced primary care, care management, and care coordination to a defined panel of CCA member’s needs through telephonic interactions.

The panel of members will be comprised of individuals with significant medical, behavioral, and social complexities that require intensive clinical support (in addition to that provided by the member’s primary care provider) that create barriers to fully and successfully accessing the health care system.

The Telephonic Care Partner is the primary clinical and care management provider for their panel of members.

Responsibilities include: comprehensive care management, chronic disease management, preventative care and wellness, liaison with relevant other providers around behavioral health and long term service and support needs, and the provision (with support) of end of life/palliative care, as needed.

Role also includes a compendium of care management/ care coordination functions encompassing the development and implementation of the member-centered individualized care plan along with authorization of appropriate services and supplies.

Do you love what you do, but maybe you’ve thought there could be a better way to do it?

In this role you will have an opportunity to: Facilitate preventative and basic interventive (primary) care to members, as needed, per CCA standard operating procedures, commonly accepted medical guidelines, and appropriate scope of practice.

Provide regularly scheduled telephonic calls to support the management of chronic disease or end of life/palliative care.

Adhere to appropriate and complete documentation practices, including: history of present illness, ordering of appropriate studies and tests, 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 telephone calls (or ensures such visits are conducted in-person) for members on panel to ensure that timely and appropriate medical care in order to avoid emergency department visit or hospitalization.

Ensure that post-discharge visits are performed for panel members within 48-hours of discharge from either an acute care facility or a skilled nursing facility to decrease risk of readmission; performs detailed medication reconciliation, adjusts medications as indicated, and ensures appropriate LTSS are in place.

Monitor and, as applicable, address clinical quality gaps (e.g., HEDIS) You will need to have a minimum of an Associate’s Degree in Nursing.

We prefer a Bachelor’s Degree in Nursing We’re looking for a minimum of 2years experience Meaningful clinical experience in primary care or care management, including: 3 years’ experience as Registered Nurse in a telephone-based setting 2 years’ experience as an RN in primary care or care management Past experience caring for patients/members with complex medical, behavioral health, and social needs strongly preferred.

Registered Nurse with licensure in good standing in Massachusetts Experience with electronic medical records (Guiding Care and eCW are a big plus) Bilingual
– English/Spanish Does this sound like you?

If you’re interested in this opportunity, please apply today.

The process takes 10-15 minutes.

We are looking for you to have: Ability to use SBAR Communication Ability to utilize an Electronic Medical Record Ability to use on-line training platforms Ability to review welcome packets and obtain consent forms and attach them to EMR Demonstrated understanding of when an updated MDS is needed Ability to complete and update a Care Plan that meets CCA requirements Demonstrated understanding of LTSS Demonstrated understanding of how to use CDSTs when ordering services Ability to create referrals and authorize services within appropriate time frames Ability to lead a family/team meeting for the purposes of discharge planning Demonstrated knowledge and ability to use screening/ assessment tools (e.g., Fall risk assessment, mini cog assessment, nutritional assessment, PHQ 2, PHQ 9, BH) Ability to conduct Crisis assessments over the phone and deploy assistance as needed Demonstrated ability of how to locate current guidelines for recommended screening tests and immunizations Demonstrated understanding of Referral to Specialists Preferred: Demonstrated understanding of, and can apply, member stratification Demonstrated understanding of how Minimum Data Set (MDS) supports stratification English required, bilingual preferred 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 zr