Telephonic Registered Nurse (Rn) Care Partner - Remote

• Facilitate preventative and basic primary care to members, as needed, per CCA standard operating procedures, commonly accepted medical guidelines, and appropriate scope of practice.
• Perform episodic urgent medical/ behavioral health telephone calls and facilitates such visits are conducted in-person for applicable members on panel to ensure that timely and appropriate medical care in order to avoid emergency department visit or hospitalization.
• Participate in activities and education to maintain and advance competency.
• Assist the member with understanding their CCA Health Benefit package.
• Provide regularly scheduled telephonic calls to support the management of chronic disease or end of life.
• Perform annual comprehensive telephonic assessments and coordinate any needed follow up from results.
• Participate in CCA quality improvement efforts.
• Liaise with CCA interdisciplinary site team where applicable and IPA clinical teams to ensure comprehensive member needs are consistently met
• MA / MI only: Reviews approved authorizations to assess appropriate utilization, based on members' needs
• Manage panel-wide and member-specific utilization trends.
• Collaborate with the Transitions of Care Team on all medical and psychiatric admissions to assist in discharge planning.
• Provide services via telehealth technologies (video, chat, etc.) for clinically appropriate clinical care and care management services.
• Coordinate a host of benefits such as transportation, community resources, interpreter services, hospice services, and more.
• Adhere 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.
• Liaise with CCA and community-based PCPs/specialists
• Actively participate in the evaluation of own performance and progress.

Working Conditions:

• Must be able to come to the local CCA office for various meetings as needed.
• May require participation in meetings across multiple states via Zoom or telephone.
• Care Partners work remotely. Must have strong internet signal.

Qualifications:

• Demonstrated ability to locate current guidelines for recommended screening tests and immunizations
• Ability to utilize an Electronic Medical Record or other electronic platforms
• Ability to conduct Crisis assessments over the phone and deploy assistance as needed
• Ability to use SBAR (Situation, Background, Assessment, Recommendation) Communication
• Demonstrated knowledge and ability to use screening/ assessment tools (e.g., Fall risk assessment, mini cog assessment, nutritional assessment, PHQ 2, PHQ 9,)
• Demonstrated understanding of how to use CDSTs when ordering services
• English required, Bilingual Spanish/Vietnamese preferred
• CCM preferred
• Ability to review welcome packets, obtain consent forms and attach them to EMR (Electronic Medical Record)
• Willing to learn and utilize telehealth technologies (video, chat, etc.), when appropriate, for a variety of clinical care and care management services.
• Ability to complete and lock all required telephone encounters within 48 hours
• Demonstrated understanding of CCA's Model of Care
• Demonstrated ability to utilize virtual care platforms
• Associate degree or Diploma in Nursing, BSN or related healthcare Degree preferred
• Past experience caring for patients/members with complex medical, behavioral health, and social needs strongly preferred.
• Experience with a Medicare Advantage population preferred.
• Ability to create referrals and authorize services within appropriate time frames
• Ability to lead a family/team meeting for the purposes of discharge planning
• 2+ years meaningful clinical experience in primary care or care management including telephonic based setting, home health or acute care case management.
• Demonstrated understanding CCA member benefits
• Demonstrated understanding of Referral to Specialists
• Experience with electronic medical records strongly preferred
• Must have an active RN license in good standing in the state assigned; may require multiple state licenses based on product
• Ability to use on-line training platforms
• Ability to complete and update a Care Plan that meets CCA requirements
• Demonstrated understanding of LTSS

Other Required:
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 these essential functions.

• While performing the duties of this job, the employee is regularly required to stand; use hands to touch, handle, or feel; reach with hands and arms; and talk or hear
• Occasionally required to walk; sit; and stoop, kneel, crouch, or crawl
• Specific vision abilities required by this job include close vision, distance vision, and ability to adjust focus
• Use of standard office equipment
• Frequently lift and/or move up to 10 pounds

Equal Opportunity Employer Minorities/Women/Protected Veterans/Disabled