Family Practice/Primary Care opening in Medford, Massachusetts. Description:
- Community Advanced Practice Clinician (C-APC) serves as leader of medical care delivery for Commonwealth Care Alliance members on an Interdisciplinary Care Team (IDT) of skilled clinicians located at Brightwood Health Center in Springfield. The C-APC works within our unique and rewarding care delivery model by conducting routine and episodic care of dually eligible members with high medical complexity. The C-APC will drive CCA's mission to improve the health and well-being of people with significant needs by innovating, coordinating, and providing the highest quality individualized care.
- Within this role, the C-APC conducts in-home and community-based visits for an assigned panel of members with complex needs. This role includes close collaboration and partnership with PCPs, Primary Care Locations (PCLs), and external care providers to develop, support, and deliver a member-centric care plan. The C-APC will liaise with the IDT to ensure significant medical, behavioral, and social determinants of health needs are met.
- Master's Degree in Nursing, Doctor of Nursing Practice or a degree in Physician Assistant Studies
- Required Licensure: Board Certified Nurse Practitioner or Physician Assistant with licensure in good standing in the Commonwealth of Massachusetts
- Must meet one of the following requirements:
- 2+ years' experience as NP or PA caring for patients/members with complex medical, behavioral health, and social needs; preferred experience in primary care or care management setting; OR
- 1-year experience as NP or PA in primary care or care management AND 3+ years' experience as Registered Nurse or EMT-P in a high touch clinical environment or home care; OR
- If new NP or PA graduate, must have 5+ years' experience as Registered Nurse or EMT-P in a high touch clinical environment or home care.
- Candidate will be required to pass credentialing process. This includes, but is not limited to:
- Current Mass Controlled Substances License required
- Current DEA Controlled Substances License required
- Current CPR or Basic Life Support (BLS) Certification Required
- Proven skills, knowledge base, and judgement necessary for independent clinical decision making in alignment with clinical licensure, ability to problem solve.
- Experience with electronic medical record strongly preferred (eCW and Guiding Care a plus)
- Experience working with managed care population
- Experience with MassHealth or Medicare programming and insurance products (i.e. ACO, MCO, PACE, or SCO)
- Perform longitudinal routine, and urgent care for an attributed member panel including:
- Medical and Psychiatric post hospital discharge visits within 48 hours with focus on hospitalization and utilization reduction
- Longitudinal chronic disease management within Complex Care Self-Management (CCSM) program
- Annual Wellness Visits
- Goals of Care conversations, including completion of HCP and MOLST forms
- Minimum Data Set (MDS) assessments
- Long Term Services and Supports (LTSS) assessments and referrals to LTSS providers
- Medication Reconciliation
- Proactive and routine well-visits and preventative care
- Urgent, episodic, or un-well visits
- Point of care testing and venipuncture
- Vaccination administration
- Routine medical follow ups and monitoring
- Conduct multiple member visits within each business day balancing routine, scheduled encounters with episodic or urgent visits.
- 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.
- Evaluate HEDIS Measure Gaps and work towards closure of gaps in clinical practice and in collaboration with member's external providers.
- Evaluate Hierarchical Condition Categories (HCC) and work to recapture.
- Leverage emergency medical or psychiatric services as indicated to mitigate Emergency Services and inpatient admissions
- $6,000 sign on bonus if hired between May 1, 2022 and August 31, 2022
- $500 a month towards student loan payment
- Mileage reimbursement (from home and between visits)
- 403B - 100% match on the first 3% contributed and 50% match on the next 3% contributed
- BCBS Medical Insurance (low cost, comprehensive coverage)
- $3,000 Tuition Reimbursement
- Company provided laptop and phone