Job Description

Why This Role is Important to Us: Commonwealth Care Alliance's (CCA) Care Planning Unit (CPU) is primarily responsible for developing and ensuring adherence to high quality, member-centric care plans through timely execution of community-based assessments for CCA members and ongoing tracking and monitoring. The Care Planner conducts timely, high quality, accurate in-person assessments. This individual leverages the Minimum Data Set (MDS) assessment and develops and documents person-centered care plan using data collected during the assessment process. This individual works collaboratively with other members of the Care Planning Unit and staff in other departments as needed to support timely interventions designed to improve outcomes for CCA members. The Care Planner reports to the Regional RN Supervisor. What You'll Be Doing: Conducts in-person assessment visits. Documents templated summary of visit highlights; documents MDS and develops initial person-centered Care Plan including current Service Plan within 48 hours of visit. Communicates any time-sensitive concerns to Regional RN Supervisor and/or NP during or immediately following visit. Reviews members with NP and BH Specialist staff in weekly Stratification meetings to validate Care Model assignment and facilitate warm hand off to Care Partner Ensures immediate referral to any time-sensitive services such as Behavioral Health, Long Term Services and Supports or Physical Therapy. Manages assessment activities through calendar and tracks status of completion Participates in assessing and improving quality within the scope of responsibilities and throughout the organization Participates in activities and education to maintain and advance clinical competencies 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 Provide clinical care to members via telehealth technologies (video, chat, etc.) for a clinically appropriate clinical care and care management services. Additional duties as requested by supervisor What We're Looking For: Qualifications: Associate's Degree in Nursing required, Bachelors Degree in Nursing preferred. RN with active registered nursing license in Commonwealth of Massachusetts, in good standing required. New Graduate, 1+ years of clinical experience including clinical rotationrequired Experience with electronic medical records strongly preferred Care Management experience strongly preferred Proven skills and knowledge base necessary for conducting clinical assessments, clinical decision makingand care delivery Ability to function independently Excellent organizational skills Ability to function effectively as part of a team Effective oral and written skills Strong Interpersonal and customer relation skills Effective teaching skills Intermediate to Advanced understanding of Microsoft Office Suite Willing to learn and utilize telehealth technologies (video, chat, etc.), when appropriate, for a variety of clinical care and care management services. English required, Bilingual preferred. #J-18808-Ljbffr Commonwealth Care Alliance

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