Care Delivery RN (Springfield/Western Massachusetts))

Job Summary:

Care Delivery RN collaborates with members of an interdisciplinary team to provide primary care, in home specialty care, and care coordination to a specific panel of high risk and complex patients, including individuals with significant medical, behavioral, and social complexities that require intensive care coordination and care delivery.


Essential Functions:

• Delivers care to complex patients, providing care management and care coordination support, and collaborating with external providers with the goal of delivering comprehensive care.
• Conducts basic health assessments and provides direct and indirect nursing care within RN scope of practice and with signed provider’s order as necessary.
• Escalates all pertinent clinical findings to assigned APC within specified timeframes.
• Conducts follow-up telephone calls with patients to ensure satisfaction.
• Assesses quality gap reports at each face-to-face visit; collaborates with care team and PCP to close identified gaps.
• Ensures timely Medical post-hospital discharge with focus on hospitalization and utilization reduction.
• Documents all visits with focus on clear, comprehensive, and concise charting while strictly adhering to 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).
• Proactively and collaboratively work with the patient’s Primary Care Provider (PCP) and other external providers on key care management/care coordination decisions to ensure a cohesive medical treatment plan is delivered.
• Participates in the interprofessional Care Team meetings, clinical committees, completes on-going education and training, and provides consultation and support to other members of Care Team.
• Assists management with the development, refinement and enhancement of clinical programs, initiatives, processes, policies, workflows, and projects.
• Completes Health Plan assessments at scheduled and timely intervals and off-cycle as needed.
• Routinely and accurately completes the member-centric Care Plan and provides updates to PCP, Providers, and HP as required.
• Regular travel to conduct member, provider and community-based visits as needed to ensure effective administration of the program.
• Supports the procurement of Durable Medical Equipment, transportation, LTSS services and supports, and community supports as approved.
• Supports the procurement of network providers and assists in closing any gaps in service or care
• Perform any other job related duties as requested.

Education and Experience:

• Associates degree in nursing required
• Bachelor's degree in nursing preferred
• Five (5) years of experience as Registered Nurse in a high touch clinical environment or home care
  required
• Two (2) years of experience caring for patients/members with complex medical, behavioral health, and social needs required
• Three (3) years of experience working in outreach or in the community caring for patients with complex medical, behavioral health, and social needs
  preferred
• Experience with electronic medical record strongly preferred
• Experience with disability issues preferred
• Experience with Medicaid or Medicare programming and insurance products (i.e. ACO, MCO, PACE, or SCO) preferred

Competencies, Knowledge and Skills:

• Excellent written and verbal communication skills
• Ability to communicate effectively with a diverse group of individuals
• Working knowledge of Microsoft Office applications
• Excellent organizational skills
• Ability to utilize an Electronic Medical Record
• Ability to use on-line training platforms
• Demonstrated understanding of Massachusetts health benefits
• Ability to review welcome packets and obtain consent forms
• Demonstrated understanding of LTSS
• Proven skills and judgment necessary for independent decision making
• Strong organizational, time management and problem-solving skills
• Ability to function effectively within a multi-disciplinary team
• Effective oral and written skills. Strong interpersonal and customer relations skills
• Ability to work with DME vendors, verifying accuracy of products and quotes
• Demonstrated proficiency with Microsoft Excel, Word, and Outlook
• Ability to learn and utilize telehealth technologies (video, chat, etc.), when appropriate, for a variety of clinical care and care management services
• Bilingual or multi-lingual preferred

Licensure and Certification:

• Current unrestricted clinica