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RN, Ready Resource Team

Company: Commonwealth Care Alliance
Location: Springfield
Posted on: October 22, 2019

Job Description:


The RN on the Ready Resource Team provides short term, episodic enhanced primary care and case management to a flexible panel of CCA beneficiaries who are dually eligible for Medicare and Medicaid, and have complex medical, behavioral health and social needs. The Ready Resource Team RN is called upon to comprehensively evaluate and formulate a management plan for members experiencing an acute event or significant change in condition. The Ready Resource Team RN provides episodic chronic disease management, urgent visits, promotes preventative care and wellness.

The role also includes providing input to members care teams on key care management/care coordination decisions, including the adjustment of the member centered care plan and identification of the need for durable medical equipment and services. The RRT RN is a resource to the clinical group and provides support to members and their care partners across all CCA models, including those served by telephonic and mobile Care Partners from various disciplines (RN, BHS, HOW). This position requires in person visits to members in their homes and will support members across Western Massachusetts.The Ready Resource Team RN reports to the Ready Resource Team Team Lead.


* Performs episodic urgent medical/ behavioral health visits to ensure that members are given timely and appropriate medical care in order to avoid emergency room or hospitalization.

* Conducts a variety of assessments within their scope of practice; including but not limited to MDS and PCA assessments.

* Facilitates and/or delivers preventative care to members according to the guidelines deemed appropriate by CCA.

* In order to decrease risk of readmission, performs post discharge visits on members within 48-hours of discharge from either an acute care facility or a skilled nursing facility; performs detailed medication reconciliation, and ensures appropriate LTSS are in place. This may include ordering appropriate DME and placing appropriate referrals.

* Collaborates with CCA Care Partner and community based PCPs/ Specialists, as needed.

* Collaborates with CCA interdisciplinary site team to ensure comprehensive member needs are consistently met (e.g., behavioral health, health outreach, chronic disease management, etc). * Provides Intermittent Skilled Care as necessary (e.g., wound care, medication management).

* Documents all activities and results using an Electronic Medical Record, in an effective manner while strictly adhering to CCA policies and procedures.

* Utilizing and depending on CCA internal resources, ensures that the plan of care is implemented in a timely manner.

* Participates in weekend schedule rotation which includes working Saturday and Sunday with 2 weekdays off in exchange. Estimated at approximately one weekend per month. This include in person visits to members in their homes to provide a variety of visits including; ex. post 48 visits, urgent visits, medication management and
wound care . * Participates in Holiday rotation.

* Participates in RN of the day rotation, which includes working in the office and providing clinical support to staff approximately once per week.


* Associate's Degree in Nursing

* Preferred: Bachelor's Degree in nursing

* Meaningful clinical experience in primary care or care management, including:

* 5+ years experience as Registered Nurse or EMT-P in a high touch clinical environment or home care or;

* 2+ years caring for patients/members with complex medical, behavioral health, and social needs Registered Nurse with licensure in good standing in Massachusetts.

* Certified in Basic Life Support for Healthcare Providers

* Experience with electronic medical record strongly preferred (eCW a plus)

* English required, bilingual preferred


* Ability to conduct and document a Pain Assessment

* Ability to use SBAR Communication

* Ability to conduct and document Home Safety Evaluation

* Ability to perform a Venipuncture

* Ability to provide Wound Care (simple & complex)

* Ability to utilize an Electronic Medical Record

* Ability to use on-line training platforms

* Demonstrated understanding of the Model of Care

* Demonstrated understanding of the benefits of each program

* Ability to review welcome packets and obtain consent forms and attach them to EMR

* Demonstrated understanding of when an updated MDS is needed

* Ability to complete a comprehensive MDS Assessment

* Ability to complete and update a Care Plan that meets CCA requirements

* Demonstrated understanding of LTSS

* Demonstrated understanding of how to use CDSTs when ordering services

* Ability to complete and lock all required notes and telephone encounters within 48 hours

* Ability to lead a family/team meeting for the pursposes of discharge planning

* Demonstrated knowledge and ability to use screening/ assessment tools (e.g., fall risk assessment, mini cog
assessment, nutritional assessment, PHQ 2, PHQ 9) * Demonstrated ability of how to locate current guidelines for recommended screening tests and immunizations

* Ability to conduct and document an Annual Comprehensive Exam

* Demonstrated ability to order diagnostic testing

* Demonstrated understanding of Referral to Specialists


* Demonstrated understanding of, and can apply, member stratification

* Demonstrates an understanding of how Minimum Data Set (MDS) supports stratification

Physical Requirements:

* The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job

* Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions

* While performing the duties of this job, the employee is regularly required to stand; use hands to finger, handle, or feel; reach with hands and arms; and talk or hear

* The employee is occasionally required to walk; sit; and stoop, kneel, crouch, or crawl

* The employee must frequently lift and/or move up to 10 pounds and occasionally lift and/or move more than 100 pounds

* Specific vision abilities required by this job include close vision, distance vision, and ability to adjust focus

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.

Keywords: Commonwealth Care Alliance, Schenectady , RN, Ready Resource Team, Healthcare , Springfield, New York

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