Hybrid Registered Nurse; RN - Care Delivery; Springfield​/Western Massachusetts

Job Summary

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 on‑going education and training, and provides consultation and support to other members of the 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.
• Regular travel to conduct member, provider and community‑based visits as needed to ensure effective administration of the program.
• Supports procurement of durable medical equipment, transportation, LTSS services and supports, and community supports as approved.
• Supports 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 a 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 (e.g., ACO, MCO, PACE, or SCO) preferred.

• Excellent written and verbal communication skills.
• Ability to communicate effectively with a diverse group of individuals.
• Working knowledge of Microsoft Office applications.
• Excellent organizational skills.
• Ability to utilize an Electronic Medical Record.
• Ability to use online training platforms.
• Demonstrated understanding of Massachusetts health benefits.
• Ability to review welcome packets and obtain consent forms.
• Demonstrated understanding of LTSS.
• Proven skills and judgment necessary for independent decision making.
• Strong organizational, time‑management and problem‑solving skills.
• Ability to function effectively within a multi‑disciplinary team.
• Effective oral and written skills. Strong interpersonal and customer‑relations skills.
• Ability to work with DME vendors, verifying accuracy of…