Why This Role is Important to Us
Commonwealth Care Alliance's (CCA) iCMP Plus ACO inter-professional teams are responsible for providing primary care and care management to a specific panel of high risk, Medicaid ACO eligible, non CCA patients. This patient group is made up of individuals with significant medical, behavioral, and social complexities that require intensive case management. This cohort of patients belong to outside organizations that are contracted with CCA to provide this complex care.
The iCMP Plus Health Mobile Advanced Practice Clinician (NP) functions within and is an integral part of an inter-professional team. This team is responsible for the care coordination and care delivery of a panel of Medicaid ACO patients. The iCMP Plus APC (NP) ensures that a defined panel of Medicaid ACO patients receives the highest quality, primary and community based skilled care within the context of a member centric individualized plan of care. The iCMP Plus APC uses evidence based care approaches, clinical skills, education, and training to influence the clinical outcomes of Medicaid ACO patients by impacting acute care utilization, ensuring optimal treatment for chronic disease management, closing of quality gaps, goals of care conversations and advance care planning.
The iCMP Plus APC collaborates daily with their inter-professional team members and maintains close contact with the patients network PCP, care providers, and specialists in the development and implementation of clinical plans of care. The iCMP Plus APC will provide ongoing chronic disease management, urgent visits, promote preventative care and wellness, and provide end of life/palliative care. The iCMP Plus APC engages in visits at regularly scheduled intervals to conduct regular assessments to ensure that their patient's Plan of Care is comprehensive and addresses significant medical, behavioral, and social needs.
This position requires in person visits to members in their homes and the community across various locations in Massachusetts.
This position reports to the iCMP Plus Clinical Manager.
What You'll Be Doing

• Performs both urgent and routine visits on members to evaluate condition and add to the plan of care
• Orders appropriate medical testing to aid in the diagnosis and medical management of acute and chronic diseases
• Leverages CCA clinical resources (InstED) to avoid emergency room visits and inpatient admissions.
• Evaluates test results, appropriately treats member illnesses and communicates/collaborates plan of care with patient's PCP
• Facilitates and/or delivers preventative care to members according the guidelines deemed appropriate by Partners ACO and CCA
• Engages in appropriate clinical collaboration with clinical experts, including the member's PCP, CCA Medical Directors, Clinical Leadership and other CCA Advanced Practice Clinicians. Guidelines may vary based on the individual make-up of the member and is based on age, comorbidities, etc.
• If appropriate, provides medical and psychiatric bridge prescribing abilities for members in transition between providers
• Evaluates member's HEDIS measure needs, write orders as appropriate to manage these gaps and follow up with PCP on results
• Assists with Advanced Directives and Advanced Care Planning, including establishing goals of care with members and obtaining MOLST forms
• Provides regularly scheduled follow up visits for the management of chronic disease. Visits are inclusive of a history of present illness, review of systems, physical exam, ordering of appropriate studies and tests, identification of a definitive diagnosis, adjustment or maintenance of an established treatment plan, and consistent follow up of the plan as evidenced in the documentation.
• Performs post discharge visits on member members within 48-hours of discharge from either an acute care facility or a skilled nursing facility to decrease risk of readmission; or a skilled nursing facility; performs detailed medication reconciliation, adjust medications as indicated, and ensure appropriate LTSS are in
• Liaises with community based PCPs/ Specialists, as
• Provides Intermittent Skilled Care as necessary (e.g., wound care,)
• Documents all activities and results using an Electronic Medical Record, in an effective manner.
• Attends weekly Interprofessional Team Meetings
• Participates in Root Cause Analysis (RCA) reviews as appropriate
• At each visit, provides member education, assesses vital signs and completes medication reconciliation.
• Formulates action/ treatment plans based on scientific rationale, evidence based standards of care and practice guidelines that demonstrate critical thinking, diagnostic reasoning and knowledge of the pathophysiology of acute and chronic disease and conditions
• Monitors the response to the action / treatment plan with appropriate and timely follow up, evaluation and initiating necessary changes in the action / treatment plan.
• Performs complex acute visits and post discharge visits.
• Completes acute care plan notes in EPIC system.
• Initiates orders and referrals for services needed.
• Per required need (estimated 6-8 times per year) responsible for assigned weekend schedule rotation which includes working Saturday, Sunday, and 2 weekdays overnight on call shifts.
• Maintains appropriate written and oral communication on a timely basis, completing documentation within 24 hours of activity, and returning non-urgent calls within 48 hours.
• Conducts educational and training activities that promote appropriate, safe and effective patient care.
• Performs handoffs with PCP's and Partners iCMP team via electronic message, phone conversation and coordination and participation in joint meetings with PCP or specialists to engage patients.
• Provides medication prescriptions.
• Assists CCA management and leadership with the development, refinement and enhancement of clinical programs, initiatives, processes, policies, workflows and projects.
• Acts as primary liaison for patients through seeking maximum patient and family participation to promote independence, advocates for patients in a culturally competent manner and working with community providers on behalf of the patient and family.
• Provide clinical care to members via telehealth technologies (video, chat, etc.) for a clinically appropriate clinical care and care management services.

• Participates in Team Case Review
• Actively participates in the evaluation of own performance and progress
• Participates in activities and education to maintain and advance competency
• Participates in CCA quality improvement efforts
• Participates in committees and workgroups that promote clinical excellence and help to advance CCAs mission and business objectives
• Maintains confidentiality of patient and employee information
• Complies with organization's policy and procedures

What We're Looking For
Qualifications:

• Master's Degree in Nursing
• 5-7 years of hands on clinical experience, defined as:
• Substantial nursing experience prior to NP (5 or more years as an RN) in a high-touch clinical environment or home care.
• 1-2 years of NP experience (preferably in primary care)
• Board certified Nurse Practitioner or Physician Assistant with licensure in good standing in the Commonwealth of Massachusetts.
• Will be required to pass CCA's and Partners credentialing process.
• Current Mass Controlled Substances License.
• Current DEA Controlled Substances License.
• Conduct and document a Pain
• Utilize SBAR Communication Technique.
• Conduct and document a Home Safety
• Provide simple and complex Wound Care.
• Utilization of multiple Electronic Medical Record (EMR), Online Training and Care Management Platforms.
• Demonstrates an understanding of the Model of Care and benefits of the iCMP Plys Program and is able to effectively communicate them to the patients.
• Demonstrates an understanding of
• Ability to lead a family/team meeting for the purposes of discharge planning
• Complete PHQ2 and PHQ9 appropriately.
• Appropriately perform venipuncture.
• Demonstrates ability of how to locate current guidelines for recommended screening tests and
• Conduct and document and Annual Comprehensive Exam
• Is able to conduct and document an Annual Comprehensive Exam and formulate Diagnosis/ Differential Diagnosis and or order diagnostic testing.
• Demonstrates an ability to prescribe
• Working Knowledge of Microsoft Office applications ( Word, Excel, PowerPoint, etc.)
• Willing to learn and utilize telehealth technologies (video, chat, etc.), when appropriate, for a variety of clinical care and care management services.
• English required, Bilingual preferred