Massachusetts Jobs

023430 Clin Alli-Clin Assessment & CP

Position Summary

Commonwealth Care Alliance’s (CCA) Care Planning Unit (CPU) is primarily responsible for developing and ensuring adherence to high quality, member-centric care plans through timely execution of community-based assessments for CCA members and ongoing tracking and monitoring.

The Care Planner conducts timely, high quality, accurate in-person assessments. This individual leverages the Minimum Data Set (MDS) assessment and develops and documents person-centered care plan using data collected during the assessment process. This individual works collaboratively with other members of the Care Planning Unit and staff in other departments as needed to support timely interventions designed to improve outcomes for CCA members.

The Care Planner reports to the Regional RN Supervisor.

Supervision Exercised: No

Essential Duties & Responsibilities

• Conducts in-person assessment visits. Documents templated summary of visit highlights; documents MDS and develops initial person-centered Care Plan including current Service Plan within 48 hours of visit.

• Communicates any time-sensitive concerns to Regional RN Supervisor and/or NP during or immediately

• following visit.

• Reviews members with NP and BH Specialist staff in weekly Stratification meetings to validate Care Model assignment and facilitate warm hand off to Care Partner

• Ensures immediate referral to any time-sensitive services such as Behavioral Health, Long Term Services and Supports or Physical Therapy.

• Manages assessment activities through calendar and tracks status of completion

• Participates in assessing and improving quality within the scope of responsibilities and throughout the organization

• Participates in activities and education to maintain and advance clinical competencies

• Seeks to maintain a constructive work environment and maintains effective communication with other

• employees and managers

• Maintains confidentiality of patient and employee information

• Complies with organization’s policy and procedures

• Provide clinical care to members via telehealth technologies (video, chat, etc.) for a clinically appropriate clinical care and care management services.

• Additional duties as requested by supervisor

Working Conditions:

• Standard office conditions.

Required Education:

• Associate's Degree in Nursing

• RN with active registered nursing license in Commonwealth of Massachusetts, in good standing

Desired Education:

• Bachelor's Degree in Nursing

Required Experience:

• 2+ years experience

• 1+ years of clinical experience in acute/medical surgical settings

• 2+ years experience in home care and/or community settings

• Care Management experience strongly preferred

Desired Experience:

• Experience with electronic medical record strongly preferred (eCW a plus)

Knowledge, Skills & Abilities (Required)

• Proven skills and knowledge base necessary for conducting clinical assessments, clinical decision making

• and care delivery

• Ability to function independently

• Excellent organizational skills

• Ability to function effectively as part of a team

• Effective oral and written skills

• Strong Interpersonal and customer relation skills

• Effective teaching skills

• Intermediate to Advanced understanding of Microsoft Office Suite

• Willing to learn and utilize telehealth technologies (video, chat, etc.), when appropriate, for a variety of clinical care and care management services.

Language(s):

• English

• Bilingual preferred

Other:

• Must be willing and able to travel to member’s homes in addition to working in an office environment

• occasionally

• Valid driver’s license with no restrictions. Ability to be active and mobile across Massachusetts

• 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 10 pounds and occasionally lift and/or move more than 100 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.