024040 Clin Alli-HICM Position Summary: Commonwealth Care Alliance’s (CCA) Community Intensive Care (CIC) program is responsible for providing care delivery and care management to a specific panel of high risk and complex people. This panel of CCA’s patients incorporates the care of individuals with significant medical, behavioral, and social complexities that require intensive care management and care delivery. Within the CIC Program, the Registered Nurse (RN) serves as an integral member of an interdisciplinary team for medical care delivery and care coordination for the most complex medical and behavioral health patients. The RN participates in providing the highest quality, community-based skilled care to a defined panel of patients within the context of a patient-centric individualized plan of care. As an integral part of an Interprofessional Care Team and based on the fluctuating needs of the defined panel of members, the Registered Nurse will engage in regular assessments, visits at regularly scheduled intervals, and conduct acute visits to ensure that members’ Plan of Care is comprehensive and addresses significant medical, behavioral, and social needs. The RN uses evidenced-based care approaches, clinical skills, education, and training to influence the clinical outcomes of assigned patients by impacting acute care utilization, ensuring optimal treatment for chronic disease management, and closing quality gaps. Additionally, the RN interfaces with the patient’s external care team members including PCPs, care providers, specialists, and vendor services, among others to maintain collaboration with the patient’s entire healthcare team. The RN utilizes all technological modalities and conducts visits within the patient’s home, community, and area facilities to ensure connection and optimize care. The RN will interface with patients during transitional space to promote hospital avoidance and readmission reduction. Additionally, the RN will assess the members basic health status, participate in planning and implementing of nursing interventions and care plans, participate in health teaching and health coaching, documentation of findings, and participation in interdisciplinary care planning. The RN will provide direct or indirect nursing care, support of health maintenance by teaching, counseling, collaborative planning, and rehabilitation support. This position requires in-person visits to patients in their homes and communities across various locations. This position reports to the CIC APC Clinical Manager. Supervision Exercised: • No, this position does not have direct reports. Essential Duties & Responsibilities: The primary function of the CICRN role is delivering care to CCA’s most complex patients, providing care management and care coordination support, and collaborating with external providers with the goal of delivering comprehensive care. Essential Duties Include – best in class patient care; clear, concise, and effective communication and documentation; and interdisciplinary collaboration with a variety of stakeholders internally and externally. Patient Care: • Conducts basic health assessments as outlined by RN licensure • Provides direct and indirect nursing care within RN scope of practice and with signed provider’s order as necessary including conducting medication reconciliations and assessing medication adherence, obtaining vital signs, performing clinical assessment, conducting wound care, perform point of care test, obtaining medication and medical records, functional status assessments, health maintenance education, and health coaching • Escalates all pertinent clinical findings to assigned APC within specified timeframes. • Performs all activities with closed loop processes. • Conducts follow-up telephone calls with patients to ensure satisfaction • Assesses quality gap reports at each face-to-face visit; collaborate with care team and PCP to close these gaps • Timely Medical post-hospital discharge with focus on hospitalization and utilization reduction. • • Documents using an Electronic Medical Record, in an effective manner while strictly adhering to CCA policies and procedures. Coordinate with the Care Partner along with the PCP and plus inter-professional care team to identify areas of opportunity, as well as defined resources. Documentation/Accountability: • Documents all visits with focus on clear, comprehensive, and concise charting. Must be able to document in English. • Completion of all tasks within appropriate timelines as outlines in Scopes of Practice and CCA Guidelines. • Comply with organization policies and procedures. • Communicates clear loop closure to the interdisciplinary care team and plans for member centric follow-ups as indicated. • Identify and initialize a plan to resolve areas of opportunity to meet Key Performance Indicators (KPIs). • Maintain patient and employee confidentiality. • Actively participates in the evaluation of own performance and progress • Provide input to patients care team on key care management/care coordination decisions. Interdisciplinary Team Collaboration: • Proactively and collaboratively work with the patient’s Primary Care Provider (PCP) and other external providers to ensure a cohesive medical treatment plan is delivered. • Conduct on-going and effective collaboration and communication with external providers, including but not limited to Primary Care staff, specialty services, LTSS coordinators, Aging Service Access Points (ASAPs), visiting nurse services, care attendants, patient designated contacts, and next of kin. • Conduct on-going and effective collaboration and communication with interdisciplinary team including but not limited to, Health Plan Care Team members, CIC Advanced Practice Clinicians, Community Health Workers, Behavioral Health Clinicians, Medical Directors, Palliative Care Team, Psychiatric services team, Rehab Team, Crisis Response workers, Patient Services representatives, administrative staff, and CCA Leaders. • Participates in the interprofessional Care Team meetings. • Provides consultation and support to other members of CIC Care Team • Participates in on-going education and training to improve skills • Assists management with the development, refinement and enhancement of clinical programs, initiatives, processes, policies, workflows, and projects. • Participates in committees and workgroups that promote clinical excellence. The CIC RN May also conduct Care Management Activities as assigned including, but not limited to: • Conducts a variety of assessments within their scope of practice, including but not limited to the Minimum Data Set (MDS), functional assessment (time for task tool), Comprehensive Assessments, LTSS Assessments, and others as they are assigned. • Completes Health Plan assessments at scheduled and timely intervals and off-cycle as indicated • Routinely and accurately completes the member-centric Care Plan and provides updates to PCP, Providers, and HP as required • Supports the procurement of Durable Medical Equipment, transportation, LTSS services and supports, and community supports as approved • Supports escalation of member grievances and appeals • Supports the procurement of network providers and assists in closing any gaps in service or care Other duties as assigned. Working Conditions: • This position requires in-person visits to patients in their homes and will support patients across various locations. • This position requires travel to CCA sites and offices per required need for various team meetings. • Valid driver’s license with no restrictions. Ability to be active and mobile across assigned catchment area. • COVID-19 vaccination is required • Compliance with all Community Clinician Occupational Health Requirements Other: Standard office equipment Physical Requirements: • The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job • Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions • While performing the duties of this job, the employee is regularly required to stand; use hands to finger, handle, or feel; reach with hands and arms; and talk or hear • The employee is occasionally required to walk; sit; and stoop, kneel, crouch, or crawl • The employee must frequently lift and/or move up to ten pounds and occasionally lift and/or move more than one hundred pounds • Specific vision abilities required by this job include close vision, distance vision, and ability to adjust focus EEO is The Law Equal Opportunity Employer Minorities/Women/Protected Veterans/Disabled 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.