Community Registered Nurse - Springfield Area
Commonwealth Care Alliance Springfield, MA
- Expired: over a month ago. Applications are no longer accepted.
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 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