CIC Advanced Practice Clinician - NP / PA - Hybrid (Hiring Immediately)

024040 Clin Alli-HICM

Position Summary

Commonwealth Care Alliances (CCA) Community Intensive Care (CIC) programing is responsible for providing care delivery and care management to a specific panel of high risk and complex people. This panel of patients incorporates the care of individuals with significant medical, behavioral, and social complexities that require intensive care management and care delivery.

Within the CIC Program, the Advanced Practice Clinician (APC - NP or PA) serves as a lead for medical care delivery and care coordination for the most complex medical and behavioral health patients. The APC functions within and is integral in a highly skilled interprofessional team model. The APC ensures that a defined panel of patients receive the highest quality, community-based skilled care within the context of a patient centric individualized plan of care. The APC uses evidence-based care approaches, clinical skills, education, and training to influence the clinical outcomes of assigned 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.

Additionally, the APC interfaces closely with the patients external care team members including PCPs, care providers, specialists, vendor services, among others to maintain collaboration with the patients entire healthcare team. The APC utilizes all technological modalities and conducts visits within the patients home, community, and area facilities to ensure connection and to optimize care. The APC will interface with patients during transitional space to promote hospital avoidance and readmission reduction. Additionally, the APC will provide ongoing chronic disease management, urgent visits, promote preventative care and wellness, and provide end of life / palliative care. The APC engages in visits at regularly scheduled intervals to conduct regular assessments to ensure that their patients Plan of Care is comprehensive and addresses significant medical, behavioral, and social needs. The APC will delegate appropriate visit follow-ups to their interprofessional care team.

This position requires in-person visits to patients in their homes and the community across various locations.

This position reports to the CIC APC Clinical Manager.

Supervision Exercised

No, this position does not have direct reports.

Essential Duties & Responsibilities

The primary function of the CIC APC role is delivering care to CCAs most complex patients, providing care management and care coordination support, and collaborating with external providers with the goal of delivering comprehensive care.

Essential Duties include - best in class patient care; clear, concise, and effective communication and documentation; and interdisciplinary collaboration with a variety of stakeholders internally and externally.

Patient Care

The APC is expected to perform longitudinal routine, and urgent care for an attributed patient panel including (but not limited to) :

• Interface with inpatient or post-acute care team and patient to optimize discharge planning in collaboration with Transitions of Care (done in-person at facility, telephonically, or virtually)
• Timely Medical post hospital discharge with focus on hospitalization and utilization reduction
• Goals of Care conversations, including completion of Health Care Proxy and MOLST forms
• Long Term Services and Supports (LTSS) assessments and referrals to LTSS providers
• Medication Reconciliation
• Proactive and routine well-visits and preventative care
• Evaluate HEDIS Measure Gaps and work towards closure of gaps in clinical practice and in collaboration with patients external providers.
• Evaluate Hierarchical Condition Categories (HCC) and work to recapture
• Urgent, episodic, or un-well visits
• Point of care testing and venipuncture
• Vaccination administration
• Routine medical follow ups and monitoring ability to delegate follow ups to appropriate support staff
• Conduct multiple patient visits within each business day balancing routine, scheduled encounters with episodic or urgent visits to maintain expected productivity
• Prescribe or bridge prescribe medications based on medical evaluation for acute and chronic conditions independently and in collaboration with PCP and / or external providers.
• Evaluate for and prescribe necessary Durable Medical Equipment (DME)
• Monitor response to action or treatment plan with appropriate evaluation and adjustments.
• Initiate necessary action or treatment changes adhering to CCA Policies and Procedures and within scope of licensure.
• Leverage emergency medical or psychiatric services as indicated to mitigate Emergency Services and inpatient admissions

Documentation / Accountability

Interdisciplinary Team Collaboration

Working Conditions

Other

Physical requirements :

Required Education (must Have)

Desired Education (nice To Have)

Required Licensing (must Have)

MA Health Enrollment (required If Licensed In Massachusetts)

Required Experience (must Have)

Must meet one of the following requirements :

2+ years experience as NP or PA caring for patients with complex medical, behavioral health, and social ne