RN Mobile - CCC

At Commonwealth Care Alliance (CCA), our vision is to lead the way in transforming the nation’s healthcare for individuals with the most significant needs. If being part of a team and working on combined solutions for patients matters to you…keep reading. We may have something to talk about.Commonwealth Community Care’s (CCC) RN-Mobile is primarily responsible for supporting a group of 5-8 Advanced Practice Clinicians (APC) with skilled nursing visits including, but not limited to, wound care, phlebotomy, INRs, foley catheter changes, disease education, and assessments for routine and urgent needs. The role also includes providing input to members’ care teams on key care management/care coordination decisions, including the adjustment of the member centered care plan and identification of the need for durable medical equipment and services.The APC, with the help of an interdisciplinary medical, social, and behavioral team, manages a panel of individuals with significant medical, behavioral, and social complexities that require intensive primary care support. The RN is an integral part of this team.The RN, Mobile reports to the APC Team Supervisor.Performs episodic urgent medical/ behavioral health visits to ensure that members are given timely andappropriate medical care in order to avoid emergency room or hospitalization. Visit includes a detailed history of present illness, review of systems, physical exam, development of a nursing treatment plan, and evidence of follow up through timely documentationFacilitates and/or delivers preventative care to members in coordination with the APC.

Identifies and initiates a plan to resolve areas of opportunity to meet quality metricsIn 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.

Liaises with CCC Care Partner and community based PCPs/ Specialists, as needed

Provides Intermittent Skilled Care as necessary (e.g., wound care,)

Documents all activities and results using an Electronic Medical Record, in an effective manner while strictly adhering to CCA policies and procedures

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)

Utilizing and depending on CCC internal resources, ensures that the plan of care is implemented in a timely manner.

Palliative care consultations and skilled interventions

Acts as a mentor to other team members to help promote/foster accountability, reliability, and independence among the other team membersProvides consultation and support to CCC team

Maintains appropriate written and oral communication on a timely basis

Conducts educational and training activities that promote appropriate, safe, effective patient care

Participates in a variety of administrative functions

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

Actively participates in the evaluation of own performance and progress

Participates in activities and education to maintain and advance competency

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

Bachelor’s Degree in NursingMeaningful clinical experience in primary care or care management, including:3+ years’ experience as Registered Nurse in a high touch clinical environment or home care setting

2+ years caring for patients/members with complex medical, behavioral health, and social needs

Required:Ability to conduct and document a Pain Assessment

Ability to use SBAR Communication

Ability to conduct and document Home Safety Evaluation

Ability to perform a Venipuncture

Ability to provide Wound Care (simple & complex)

Ability to utilize an Electronic Medical Record

Ability to use on-line training platforms

Ability to complete a comprehensive MDS Assessment

Ability to complete and update a Care Plan that meets CCA requirements

Demonstrated understanding of LTSS

Ability to complete and lock all required notes and telephone encounters within 48 hours

Ability to lead a family/team meeting for the purposes of discharge planning

Demonstrated knowledge and ability to use screening/ assessment tools (e.g., fall risk assessment, mini cog assessment, nutritional assessment, PHQ 2, PHQ 9)

Demonstrated ability of how to locate current guidelines for recommended screening tests and immunizations English required, bilingual preferredStandard office equipmentStandard Medical Equipment including a hoyer liftExperience with electronic medical record strongly preferred (eCW a plus)The physical demands described here are representative of those that must be met by an employee tosuccessfully perform the essential functions of this jobReasonable 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 than100 pounds. Specific vision abilities required by this job include close vision, distance vision, and ability to adjust focus

Job Title for Posting: RN Mobile - CCC ID: 2020-3501 External Company Name: Commonwealth Care Alliance, Inc. External Company URL: http://www.commonwealthcarealliance.org/ Actual Work Location: CCC Clinic, 30 Northampton Street, Boston, MA