Commonwealth Care Alliance’s (CCA) Community Weekend Registered Nurse (RN) ensures the highest quality, primary and community based skilled care is provided to CCA members, a group of individuals with significant medical, behavioral, and social complexities that require intensive clinical support, within the context of a member centric individualized plan of care.
The Community Weekend RN has the opportunity to use evidence-based practice, clinical skills, education, and training to influence the clinical outcomes of CCA’s membership 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 Weekend RN will collaborate with the member’s network PCP, providers, and specialists in the development and implementation of clinical plans of care.
As an integral part of the Care Team the Community Weekend RN will engage in regular assessments for MDS assessments, LTSS assessments and skilled care, perform post discharge assessments on members following discharge from a facility, and conduct acute visits to ensure that members’ Plan of Care is comprehensive and addresses significant medical, behavioral, and social needs.
This position requires in person visits to members in their homes or in the community and will support members across various location in Massachusetts.
Friday: 8:30 – 5:00
Saturday: 8:30 am – 9:00 pm
Sunday: 8:30 am – 9:00 pm
THIS POSITION WILL SUPPORT THE SPRINGFIELD, MA AREA
- Performs episodic urgent medical/ behavioral health visits to ensure that members are given timely and appropriate medical care 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.
- 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, performs Intermittent Skilled Care as necessary (e.g., wound care, medication management, routine and chronic disease assessment and other skilled needs).
- With a signed Provider’s order, performs palliative care skilled interventions
- Provides education to member and family, as appropriate
- Assesses quality gap reports at each face to face visit; collaborate with care team and PCP to close these gaps
- Assesses MDS needs prior to every visit and complete MDS assessment if due within 60 days
- Completes fall log as appropriate
- Attends weekly Team Meetings and participates in case conferences
- Attends weekly 1:1 supervision with manager
- 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.
- Adjusts the member centered plan of care as necessary based on a significant change in condition
- Identifies members who require escalation to the APC or MD for further evaluation
- Associate’s Degree in nursing required, Bachelor’s Degree in nursing preferred.
- Experience in managed care/insurance preferred
- Meaningful clinical experience in care management preferred
- 3+ years’ experience as an RN in home health care or case 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
- RN licensure in good standing in the Commonwealth of Massachusetts.
- Current CPR or Basic Life Support (BLS) Certification
- Demonstrate an understanding of the benefits of CCA’s product lines
- Palliative care skills/interventions
- Chronic disease management and Behavioral Health experience
- Phlebotomy skill and knowledge required
- Wound care experience/knowledge (simple and complex)
- Able to work independently in the field
- Able to organize, manage and prioritize clinical needs
- Provide healthcare education to members
- Communicate with on-call MDs and on-call PCPs
- Able to work in a fast-paced environment and able to change priorities as needed
- Pain management knowledge and pain education
- Able to utilize Electronic Medical Records (EMR)
- Is able to use SBAR communication
- Experience with technology (outlook, word)
- English required, bilingual preferred (Spanish, Haitian-Creole, Russian)
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
Commonwealth Care Alliance