Commonwealth Community Care's (CCC) Care Partner Team is primarily responsible for providing longitudinal care coordination, and primary care delivery to a dedicated panel of members, a group of individuals with significant medical, behavioral, and social complexities that require intensive clinical support.
The NP or PA, Care Partner (Mobile) will provide ongoing chronic disease management, urgent visits, preventative care and wellness visits, and provide end of life/palliative care with support from internal specialists. Role also includes a compendium of care management/ care coordination functions encompassing the development and implementation of the member-driven individualized care plan along with authorization of appropriate durable medical equipment and services.
• Primary care to members – Provides patient-centered, comprehensive home-based primary care to complex adult and geriatric patients (assessment, diagnosis, treatment, referrals) to promote continuity of care by coordinating with PCP and other providers as necessary.
• Specialty care to members – Provides urgent/sick/episodic care, post-hospital care and palliative care. Coordinates other specialty services such as behavioral health, psychopharmocotherapy and health education in collaboration with PCPs and CCA clinical specialists as needed.
• Professionalism – Exhibits professionalism and the translation of CCA’s mission into patient-centered activities and plans of care.
• Risk adjustment – Performs and documents Annual Comprehensive Assessments on a panel of members ensuring that CCA is properly funded and quality, patient-centered care is provided. Performs ongoing history, exam and medical decision making including pharmacotherapy in collaboration with internal and external providers.
• On call – Provides all services listed above on weekends and holidays, including making visits as needed, in an on-call rotation with NP/PA and RN colleagues.
• Clinical documentation – Provide expert-level comprehensive documentation in the clinical record to reflect the true complexity of each member’s biopsychosocial condition.
• Continuing education – Participates in ongoing educational activities and formal CME/CEU courses to advance knowledge base and skills competency and to maintain required licensure and certification
• Quality Assurance – Ensures that clinical service delivery meets CCA standards as outlined in policies and standing operating procedures. Reviews quality metrics and develops plans to address deficiencies or substandard outcomes accordingly
• Teamwork – Works effectively and collaboratively with colleagues to ensure satisfactory patient outcomes and maintains patient panel in collaboration with RN co-care manager.
• Leadership – Provides consulting and mentoring to new clinicians and CCA Primary Care Teams. Models professionalism and the translation of CCA's mission into patient-centered activities and plans of care
• Autonomy – Works effectively and independently to problem solve. Uses appropriate time management and offers flexibility in team setting. Takes ownership of clinical decisions and offers consultation and guidance to peers. Offers constructive solutions to problems and is able to make clinical suggestions for further patient care.
• Skills Building – Has willingness to learn new and develop existing clinical skills, including a broad range of nursing tasks. Provides positive and constructive feedback for workflow processes.
• Graduation from an accredited NP or PA program
• ANCC or AANP certification for NPs and NCCPA certification for PAs
• Licensure to practice in the state of MA
• Mass Controlled Substance Registration
• DEA Registration
• Current BLS for Healthcare Providers Certification
• Relevant work or education-related clinical experience required.
• Proven skills and knowledge necessary for independent clinical decision making at the NP/PA level
• Must have strong primary care skills. Proficient in taking medical history, performing physical exam and assessment, determining differential diagnosis based on symptoms and exam findings, ordering and interpreting laboratory and diagnostic tests, and utilizing clinical judgment to determine appropriate treatment plan.
• Must be comfortable working with patients who have behavioral health diagnoses; psychiatric disorders, substance abuse or addictions
• Makes independent clinical decisions daily that affects clinical and financial outcomes while utilizing Clinical Decision Support Tools
• Collaborates with administrative, clinical and medical leadership on decisions that are not directly related to patient care
• Decision making involves diagnosing, treating and prescribing medications and medical therapeutics. Decisions around assessment and testing, ethical dilemas, complex clinical situations and service needs are made in conjunction with the clinical team and with reference to CCA’s Clinical Decision Support Tools.
• Complexity of this role is advanced
• On a daily basis, makes independent and collaborative medical decision on complex patients in a fast-paced and constantly evolving work environment
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