Care Delivery RN; Boston and - R12958

Commonwealth Care Alliance® (CCA) is a nonprofit, mission‑driven health plan and care delivery organization designed for individuals with the most significant needs. As an affiliate of Care Source, a nationally recognized nonprofit managed care organization with over 2 million members across multiple states, CCA serves individuals enrolled in Medicaid and Medicare in Massachusetts through the Senior Care Options and One Care programs and its care delivery enterprises.

CCA is dedicated to delivering comprehensive, integrated, and person‑centered care, powered by its unique model of uncommon care®, which yields improved quality outcomes and lower costs of care.

Care Delivery RN collaborates with members of an interdisciplinary team to provide primary care, in‑home specialty care, and care coordination to a specific panel of high‑risk and complex patients, including individuals with significant medical, behavioral, and social complexities that require intensive care coordination and care delivery.

• Delivers care to complex patients, providing care management and care coordination support, and collaborating with external providers with the goal of delivering comprehensive care.
• Conducts basic health assessments and provides direct and indirect nursing care within RN scope of practice and with signed provider’s order as necessary.
• Escalates all pertinent clinical findings to assigned APC within specified time frames.
• Conducts follow‑up telephone calls with patients to ensure satisfaction.
• Assesses quality gap reports at each face‑to‑face visit; collaborates with care team and PCP to close identified gaps.
• Ensures timely medical post‑hospital discharge with focus on hospitalization and utilization reduction.
• Documents all visits with focus on clear, comprehensive, and concise charting while strictly adhering to policies and procedures.
• Communicates clear loop closure to the interdisciplinary care team and plans for member‑centric follow‑ups as indicated.
• Identifies and initiates a plan to resolve areas of opportunity to meet Key Performance Indicators (KPIs).
• Proactively and collaboratively works with the patient’s Primary Care Provider (PCP) and other external providers on key care management/care coordination decisions to ensure a cohesive medical treatment plan is delivered.
• Participates in the interprofessional Care Team meetings, clinical committees, completes ongoing education and training, and provides consultation and support to other members of Care Team.
• Assists management with the development, refinement and enhancement of clinical programs, initiatives, processes, policies, workflows, and projects.
• Completes Health Plan assessments at scheduled and timely intervals and off‑cycle as needed.
• Routinely and accurately completes the member‑centric Care Plan and provides updates to PCP, Providers, and HP as required.
• Regularly travels to conduct member, provider and community‑based visits as needed to ensure effective administration of the program.
• Supports the procurement of Durable Medical Equipment, transportation, LTSS services and supports, and community supports as approved.
• Supports the procurement of network providers and assists in closing any gaps in service or care.
• Performs any other job‑related duties as requested.

• Associate’s degree in nursing required.
• Bachelor's degree in nursing preferred.
• Five (5) years of experience as Registered Nurse in a high‑touch clinical environment or home care required.
• Two (2) years of experience caring for patients/members with complex medical, behavioral health, and social needs required.
• Three (3) years of experience working in outreach or in the community caring for patients with complex medical, behavioral health, and social needs preferred.
• Experience with electronic medical record strongly preferred.
• Experience with disability issues preferred.
• Experience with Medicaid or Medicare programming and insurance products (i.e., ACO, MCO, PACE, or SCO) preferred.

• Excellent written and verbal communication skills.
• Ability to communicate effectively with a diverse group of individuals.
• Worki…