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Telephonic RN

Company: Commonwealth Care Alliance
Location: Charlestown
Posted on: April 10, 2021

Job Description:

Job DescriptionFacilitates preventative and basic primary care to members, as needed, per CCA standard operating procedures, commonly accepted medical guidelines, and appropriate scope of practice. Provides regularly scheduled telephonic calls to support the management of chronic disease or end of life/ - Assist the member with understanding their CCA Health Benefit package Tracks MDS due dates and assist in scheduling MDS assessments Adheres to appropriate and complete documentation practices, including: history of present illness, adjustment or maintenance of an established treatment plan, and consistent follow up of the plan as evidenced in the documentation. Performs episodic urgent medical/ behavioral health telephone calls and facilitates 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. Ensures that post-discharge visits are performed for panel members within 48-hours of discharge from an acute care facility, Psychiatric or a skilled nursing facility to decrease risk of readmission. Performs detailed medication reconciliation, as appropriate, based on licensure Ensures appropriate LTSS are in place and collaborates with GSSC/LTSC on members' needs Review the Quality Gap Report weekly and addresses clinical quality gaps (e.g., HEDIS), collaborating with the community APC and RNs on the team, along with the member's PCP Liaises with CCA interdisciplinary site team to ensure comprehensive member needs are consistently met - Manages panel-wide and member-specific utilization trends Liaises with CCA and community-based PCPs/specialists Ensures appropriate documentation of visits and activities within CCA's central enrollee record and within 48 hours of visits - Participates in weekly Interprofessional Team Meetings Collaborates with the Transitions of Care Team on all medical and psychiatric admissions to assist in discharge planning Adjusts the member-centered plan of care as necessary based on a significant change in condition. A change in condition is an event (hospitalization, acute illness, etc.) which results in either a short- or long-term change in need (examples include adding in Palliative care, increasing personal care hours short term post hospitalization, or purchasing high cost durable medical equipment for a non-reversible functional change) Utilizes Clinical Decision Support Tools, team meetings, and consultation with CCA specialists, authorizes proposed equipment and/or services for the implementation of the individualized plan of care and collaborates with CCA Utilization Management staff to ensure appropriate medical necessity criteria are met. Participates in utilization and case review as necessary

Keywords: Commonwealth Care Alliance, Boston , Telephonic RN, Healthcare , Charlestown, Massachusetts

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