Telephonic Registered Nurse (Rn) Case Manager - Remote

Commonwealth Care Alliance’s (CCA) Care Partner is primarily responsible for providing comprehensive care coordination and care management to CCA members from one or moreCCA benefit programs.

The Care Partner provides care management, and care coordination to a defined panel of CCA members and is the primary clinical and care management provider for this panelof members. Responsibilities include comprehensive care management, chronic disease management, preventative care and wellness, liaison with other relevant providers aroundbehavioral health and long-term service and support needs, and the provision (with support) of end of life/palliative care, as needed.

This role also includes a compendium of care management/care coordination functions encompassing the development and implementation of the member-centered individualized careplan, along with oversight and authorization of appropriate services and supplies.

• Participate in activities and education to maintain and advance competency.
• Facilitate preventative and basic primary care to members, as needed, per CCA standard operating procedures, commonly accepted medical guidelines, and appropriatescope of practice.
• Reviews approved authorizations to assess appropriate utilization, based on members’ needs
• Promote and enforce CCA’s compliance program
• 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.
• Assist the member with understanding their CCA Health Benefit package.
• 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.
• Adhere to CCA’s Policy & Procedures
• Provide regularly scheduled telephonic calls to support the management of chronic disease or end of life.
• Provide services via telehealth technologies (video, chat, etc.) for clinically appropriate clinical care and care management services.
• Actively participate in the evaluation of own performance and progress.
• Ensure confidentiality of member and company proprietary information is maintained
• Review Code of Conduct at least annually and promote and enforce CCA’s Code of Conduct
• Demonstrate accountability by delivering on commitments, owning mistakes as well as successes, and contributing to an empowering environment where the focus is on solving problems and learning from errors. Recognize and respect diversity in all forms. Strive for excellence in the fulfillment of CCA’s mission through quality, innovation, and continuous learning. Demonstrate initiative, flexibility, and openness to change. Represent CCA and its clinical affiliates with professionalism. Keep current and proficient with necessary skills and knowledge. Self-identify training and development needs relevant to work area and responsibilities. Adhere to all applicable compliance requirements including but not limited to:
• Care Partners work remotely. Must have strong internet signal.
• Complete required compliance training in a timely manner
• Liaise with CCA interdisciplinary site team where applicable and IPA clinical teams to ensure comprehensive member needs are consistently met
• Coordinate a host of benefits such as transportation, community resources, interpreter services, hospice services, and more.
• Participate in CCA quality improvement efforts.
• Promptly, in good faith, report any instances of suspected fraud, waste, and abuse; suspected privacy and/or security incidents; or any compliance concerns identified
• Liaise with CCA and community-based PCPs/specialists
• Manage panel-wide and member-specific utilization trends.
• Perform annual comprehensive telephonic assessments and coordinate any needed follow up from results.
• May require participation in meetings across multiple states via Zoom or telephone.
• Demonstrate integrity by working with passion, commitment, and honesty, acting in the best interests of colleagues and members. Approach work in a collaborating and caring manner interacting with insight, sincerity, and compassion.
• Collaborate with the Transitions of Care Team on all medical and psychiatric admissions to assist in discharge planning.
• Must be able to come to the local CCA office for various meetings as needed.

Qualifications:

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