Job Summary:

Care Delivery RN collaborates with members of an interdisciplinary team to provide primary care, in home specialty care, and care coordination to a specific panel of high risk and complex patients, including individuals with significant medical, behavioral, and social complexities that require intensive care coordination and care delivery.


Essential Functions:

• Delivers care to complex patients, providing care management and care coordination support, and collaborating with external providers with the goal of delivering comprehensive care.
• Conducts basic health assessments and provides direct and indirect nursing care within RN scope of practice and with signed provider’s order as necessary.
• Escalates all pertinent clinical findings to assigned APC within specified timeframes.
• Conducts follow-up telephone calls with patients to ensure satisfaction.
• Assesses quality gap reports at each face-to-face visit; collaborates with care team and PCP to close identified gaps.
• Ensures timely Medical post-hospital discharge with focus on hospitalization and utilization reduction.
• Documents all visits with focus on clear, comprehensive, and concise charting while strictly adhering to policies and procedures.
• Communicates clear loop closure to the interdisciplinary care team and plans for member centric follow-ups as indicated.
• Identify and initialize a plan to resolve areas of opportunity to meet Key Performance Indicators (KPIs).
• Proactively and collaboratively work with the patient’s Primary Care Provider (PCP) and other external providers on key care management/care coordination decisions to ensure a cohesive medical treatment plan is delivered.
• Participates in the interprofessional Care Team meetings, clinical committees, completes on-going education and training, and provides consultation and support to other members of Care Team.
• Assists management with the development, refinement and enhancement of clinical programs, initiatives, processes, policies, workflows, and projects.
• Completes Health Plan assessments at scheduled and timely intervals and off-cycle as needed.
• Routinely and accurately completes the member-centric Care Plan and provides updates to PCP, Providers, and HP as required.
• Regular travel to conduct member, provider and community-based visits as needed to ensure effective administration of the program.
• Supports the procurement of Durable Medical Equipment, transportation, LTSS services and supports, and community supports as approved.
• Supports the procurement of network providers and assists in closing any gaps in service or care
• Perform any other job related duties as requested.

Education and Experience:

• Associates degree in nursing required
• Bachelor's degree in nursing preferred
• Five (5) years of experience as Registered Nurse in a high touch clinical environment or home care
  required
• Two (2) years of experience caring for patients/members with complex medical, behavioral health, and social needs required
• Three (3) years of experience working in outreach or in the community caring for patients with complex medical, behavioral health, and social needs
  preferred
• Experience with electronic medical record strongly preferred
• Experience with disability issues preferred
• Experience with Medicaid or Medicare programming and insurance products (i.e. ACO, MCO, PACE, or SCO) preferred

Competencies, Knowledge and Skills:

• Excellent written and verbal communication skills
• Ability to communicate effectively with a diverse group of individuals
• Working knowledge of Microsoft Office applications
• Excellent organizational skills
• Ability to utilize an Electronic Medical Record
• Ability to use on-line training platforms
• Demonstrated understanding of Massachusetts health benefits
• Ability to review welcome packets and obtain consent forms
• Demonstrated understanding of LTSS
• Proven skills and judgment necessary for independent decision making
• Strong organizational, time management and problem-solving skills
• Ability to function effectively within a multi-disciplinary team
• Effective oral and written skills. Strong interpersonal and customer relations skills
• Ability to work with DME vendors, verifying accuracy of products and quotes
• Demonstrated proficiency with Microsoft Excel, Word, and Outlook
• Ability to learn and utilize telehealth technologies (video, chat, etc.), when appropriate, for a variety of clinical care and care management services
• Bilingual or multi-lingual preferred

Licensure and Certification:

• Current unrestricted clinical license in Massachusetts as a Registered Nurse required
• Basic Life Support Certification required
• Must have valid driver's license, vehicle and verifiable insurance. Employment in this position is conditional pending successful clearance of a driver’s license record check. If the driver’s license record results are unacceptable, the offer will be withdrawn or, if employee has started employment in position, employment in this position will be terminated
• To help protect our employees, members, and the communities we serve from acquiring communicable diseases, Influenza vaccination is a requirement of this position. CareSource requires annual proof of Influenza vaccination for designated positions during Influenza season (October 1 – March 31) as a condition of continued employment. Employees hired during Influenza season will have thirty (30) days from their hire date to complete the required vaccination and have record of immunization verified.
• CareSource adheres to all federal, state, and local regulations. CareSource provides reasonable accommodations to qualified individuals with disabilities or medical conditions, sincerely held religious beliefs, or as required by state law to enable the employee to perform the essential functions of the position. Request for accommodations will be completed through an interactive review process.

Working Conditions:

• This is a mobile position, meaning that regular travel to different work locations, including homes, offices or other public settings, is essential.
  Will be exposed to weather conditions typical of the location and may be required to stand and/or sit for long periods of time.
  Must reside in the same territory they are assigned to work in; exceptions may be considered, due to business need
  May be required to travel greater than 50% of time to perform work duties.
  Required to use general office equipment, such as a telephone, photocopier, fax machine, and computer
  Flexible hours, including possible evenings and/or weekends as needed to serve the needs of our members
• The employee must frequently lift and/or move up to ten pounds and occasionally lift and/or move more than one hundred pounds
   
• Over 50% (Mobile) Routine travel required

Compensation Range:

CareSource takes into consideration a combination of a candidate’s education, training, and experience as well as the position’s scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. In addition to base compensation, you may qualify for a bonus tied to company and individual performance. We are highly invested in every employee’s total well-being and offer a substantial and comprehensive total rewards package.

Compensation Type (hourly/salary):

Organization Level Competencies

• Fostering a Collaborative Workplace Culture

• Cultivate Partnerships

• Develop Self and Others

• Drive Execution

• Influence Others

• Pursue Personal Excellence

• Understand the Business

This job description is not all inclusive. CareSource reserves the right to amend this job description at any time. CareSource is an Equal Opportunity Employer. We are dedicated to fostering an environment of belonging that welcomes and supports individuals of all backgrounds.