Commonwealth Care Alliance's (CCA) iCMP Plus ACO inter-professional teams are responsible for providing primary care and care management to a specific panel of high-risk, Medicaid ACO eligible, non CCA patients. This patient group is made up of individuals with significant medical, behavioral, and social complexities that require intensive case management. This cohort of patients belongs to outside organizations that are contracted with CCA to provide this complex care.

The iCMP Plus ACO Mobile RN functions within and is an integral part of an inter-professional team. This team is responsible for the care coordination and care delivery of a panel of Medicaid ACO patients. The iCMP Plus Mobile RN ensures that a defined panel of Medicaid ACO patients receives the highest quality, primary and community based skilled care within the context of a member centric individualized plan of care. The iCMP Plus RN uses evidence based care approaches, clinical skills, education, and training to influence clinical outcomes and utilization patterns. The iCMP Plus RN provides chronic disease management, addresses home based community service utilization, holds goals of care conversations, develops collaborative advanced care planning and provides skilled nursing services that support optimal self-management, and palliative and end of life care. .

The iCMP Plus Mobile RN collaborates daily with their inter-professional team members and maintains close contact with the member's network PCP, care providers, and specialists in the development and implementation of clinical plans of care. The iCMP Plus RN engages in regular assessments, visits at regularly scheduled intervals, and conduct acute visits to ensure that members' Plan of Care is comprehensive and addresses significant medical, behavioral, and social needs.

The iCMP Plus RN is supported by a fully staffed inter-professional care team and collaborates with the entire care team. The iCMP Plus RN keeps team clinicians and extended team members (within CCA and in the patients Network) well informed by providing critical clinical information that helps drive the overall goal of care. The iCMP Plus RN makes adjustments to the care plan by identifying and addressing gaps and, in concert with team members, will leverage covered benefits to ensure that the right mix of community services and DME are in place to meet the patient's unique needs.

• This position requires in person visits to members in their homes and will support members across various locations in Massachusetts.

• Associate's Degree in nursing required,Bachelor's Degree in nursing preferred.
• Registered Nurse with licensure in good standing in Massachusetts.
• Certified in Basic Life Support for Healthcare Providers.
• Current CPR or Basic Life Support (BLS)
• Meaningful clinical experience in primary care or care management.
• 5+ years' experience as Registered Nurse in a high touch clinical environment or home care
• Demonstrate an understanding of the benefits of Mass Health Standard and CCA product lines
• Is able to conduct and document a Pain Assessment
• Is able to use SBAR Communication
• Is able to conduct and document Home Safety Evaluation
• Is able to provide Wound Care (simple & complex)
• Is able to utilize an Electronic Medical Record
• Is able to use on-line training platforms
• Demonstrates an understanding of the Medicaid ACO and their role supporting patients in this program as an employee of CCA
• Demonstrates an understanding of the benefits of each program
• Is able to review welcome packets and obtain consent forms and attach them to EMR
• Is able to complete and update a Care Plan
• Demonstrates an understanding of community services
• Is able to complete and lock all required notes and telephone encounters within 48 hours
• Participates in case discussions
• Ability to conduct Crisis assessments over the phone and deploy assistance as needed
• Able to lead a family/team meeting for the purposes of discharge planning
• Returns all non-urgent calls within 1 day and urgent calls as soon as possible
• Obtains/documents a comprehensive history
• Demonstrates knowledge and ability to use screening/ assessment tools that identify risk
• Assist with Advanced Care Planning, including establishing goals of care with members
• 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