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

Position: Care Delivery - Registered Nurse (RN) - Hybrid (Springfield/Western Massachusetts))
## Care Delivery RN (Springfield/Western Massachusetts))Apply locations:
Massachusetts Mobile time type:
Full time posted on:
Posted Yesterday job requisition :
R12957
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* 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.

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* Essential Functions:

*** 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.
* Identify and initialize a plan to resolve areas of opportunity to meet Key Performance Indicators (KPIs).
* Proactively and collaboratively work 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 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 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
* Perform any other job related duties as requested.
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* Education and Experience:

*** Associates 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
** Competencies, Knowledge and

Skills:

*** 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 on-line 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…