- 3 or more years of APC experience
- Board certified NP or PA
- Geriatric/adult training and experience
- Daily access to a vehicle and a valid driver’s license
- Willing to have a territory along the 91 Corridor that is approx a 30 mile radius
Description of Role
Ready Resource Team (RRT) is primarily responsible for providing short-term in-person episodic care and care management to a flexible panel of dually-eligible organization members, a group of individuals with significant medical, behavioral, and social complexities that require intensive clinical support.
The population is made up of members across all organization models, including those served by telephonic and mobile Care Partners from various disciplines (RN, BHS, HOW.) The RRT APC also serves as a clinical content and patient face-to-face engagement expert to support mobile and telephonic teams in the palliative/ end of life care, chronic disease management, behavioral health prescribing, pain management, and other urgent issues. The RRT APC will provide short-term, episodic chronic disease management, make urgent visits, promote preventative care and wellness, and provide end of life/palliative care. The role also includes performing a discrete set of care management/care coordination functions, including the adjustment of the member-centric care plan and authorization of appropriate durable medical equipment and services.
Travel – the candidate will be assigned a territory along the 91 Corridor that is approx a 30 mile radius. Schedule – M-F 8:30-5, the candidate will be able to schedule patients based on their needs. IE they can see all their patients in the AM and chart in the afternoon, or vice versa. Very flexible! Experience – experience assessing, diagnosing, and treating is critical in this role.
Must have at least 1 year of NP or PA experience to be successful in this position.
GREAT Benefits – Including $500/month in loan forgiveness along with $3,000/year in tuition assistance for further education
- 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. Visit includes a detailed history of present illness, review of systems, physical exam, ordering of appropriate studies and tests, identification of a definitive diagnosis, development of a treatment plan, and evidence of follow up through timely documentation
- Facilitates and/or delivers preventative care to members according to the guidelines deemed appropriate by organization Clinical Leadership. Guidelines may vary based on the individual make-up of the member and is based on age, comorbidities, etc.
- Provides limited regularly scheduled follow up visits for the management of chronic disease or end of life/palliative care.
- In order to decrease the 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, adjust medications as indicated, and ensure appropriate LTSS are in place.
- Provides Intermittent Skilled Care as necessary (e.g., wound care,)
- Documents all activities and results using an Electronic Medical Record, in an effective manner while strictly adhering to Organizations policies and procedures
- Adjusts the member-centered plan of care as necessary based on a significant change in condition. A change in condition is an event (hospitalization, acute illness, etc.) which results in either a short or long-term change in need (examples include adding in Palliative care, increasing personal care hours short-term post-hospitalization, or purchasing high cost durable medical equipment for a non-reversible functional change) Utilizing and depending on organizations internal resources, ensures that the plan of care is implemented in a timely manner.
- Performs defined functions of the authorization process as indicated by organizations policies and procedures.
- Palliative care consultations and skilled interventions
- Participates in “weekend schedule” rotation which includes working Saturday, Sunday, and 2 weekdays. Estimated at 6-8 times per year
- Master’s degree in nursing required Board Certified NP or Physician Assistant with licensure in good standing in the Commonwealth of Massachusetts, required
- . Meaningful clinical experience in primary care or care management, including: 3+ years’ experience as an NP in primary care or care management; AND 2+ years caring for patients/ members with complex medical, behavioral health, and social needs
This facility is an equal opportunity employer and complies with federal, state and local anti-discrimination laws, regulations and ordinances