Care Planner RN
Work Location - Springfield and surrounding communities
Commonwealth Care Alliance
Commonwealth Care Alliance is a rapidly growing nonprofit organization providing integrated health care and social support services to people with complex medical needs. Our patients are seniors and persons with disabilities covered under Medicaid or both Medicaid and Medicare. Our innovative care model is nationally recognized for its effectiveness in improving health outcomes for these vulnerable populations.
Our unique care model is empowering for our employees as well as our members. Whether you are a clinical or administrative professional, all of us at Commonwealth Care Alliance receive the satisfaction of knowing our work truly makes a difference. We enjoy a company culture of passionate advocacy in a supportive work environment with opportunities for growth and learning, competitive salaries, and a generous and comprehensive benefit package.
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 RN will be covering the North Shore.
- 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 RN Manager 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.
- Ensures immediate referral to any time-sensitive services such as Behavioral Health 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
- Actively participates in the evaluation of own performance and progress
- 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
- Associate's Degree in Nursing required
- Bachelor's Degree in Nursing preferred
- RN with active registered nursing license in Commonwealth of Massachusetts, in good standing
- 1+ years of clinical experience in acute/medical surgical settings
- 2+ years of experience in home care and/or community settings
- Discharge planning and Case Management experienced strongly preferred
Knowledge, Skills and Abilities
- Proven skills and knowledge base necessary for conducting clinical assessments, clinical decision making and care delivery
- Ability to function independently and seek assistance with unusual problems
- Excellent organization 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
- Must be willing and able to travel to member’s homes on the North Shore in addition to working in an office environment occasionally
- Valid driver’s license with no restrictions; ability to be active and mobile across Massachusetts
- English required, bilingual preferred
Commonwealth Care Alliance is an equal opportunity employer. Applicants are considered for positions without regard to veteran status, uniformed service member status, race, color, religion, sex, national origin, age, physical or mental disability, genetic information or any other category protected by applicable federal, state or local laws