The Community Advanced Practice Clinician ensures that a defined panel of dually eligible individuals receives the highest quality, primary care within the context of a member centric individualized plan of care.
As the Community APC you will have the opportunity to use evidence, clinical skills, education, and training to influence the clinical outcomes of CCA’s members by impacting acute care utilization, ensuring optimal treatment for chronic disease management, closing of quality gaps, participation in Annual/Geriatric Assessments, goals of care conversations, advance care planning, and delivering palliative and end of life care.As the Community APC you will maintain close contact and collaboration with the member’s network PCP, providers, and specialists in the development and implementation of clinical plans of care.
As an integral part of an Inter-professional Care Team and based on the fluctuating needs of the defined panel of members, you will engage in regular assessments, visits at regularly scheduled intervals, and conduct acute visits to ensure that members’ Plan of Care is comprehensive and addresses significant medical, behavioral, and social needs. Engagement by the APC can occur in two different ways.
Episodic care is triggered by an acute event or significant change in condition of a member which necessitates close, short term follow up by an Advanced Practice Clinician. Longitudinal enhanced primary care is delivered to members who are medically complex, with limitations that create a barrier for traditional in office visits.
This 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.
This position will cover territory North of Boston (Haverhill, Methuen, Lawrence, N. Andover)
- You will be able to performs both urgent and routine visits on members to evaluate condition and add to the plan of care
- You will order appropriate medical testing to aid in the diagnosis and medical management of acute and chronic diseases
- You will also leverage CCA clinical resources (InstED) to avoid emergency room visits and inpatient admissions.
- We will also want you to evaluate test results, appropriately treat member illness and communication/collaborate plan with PCP
- In addition, you will be facilitate and/or deliver preventative care to members according the guidelines deemed appropriate by CCA
- You will engage in appropriate clinical collaboration with clinical experts, including the member’s PCP, CCA Medical Directors, and other CCA Advanced Practice Clinicians. Clinical Leadership. Guidelines may vary based on the individual make-up of the member and is based on age, comorbidities, etc.
- You will provide care to those who need it most by...
- If appropriate, provide medical and psychiatric bridge prescribing abilities for members in transition between providers
- Evaluate member’s HEDIS measure needs, write orders as appropriate to manage these gaps and follow up with PCP on results
- Assist with Advanced Care Planning, including establishing goals of care with members and obtaining MOLST forms
- Provides limited 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.
- You will need a minimum of a Master’s Degree in Nursing or a Master's Degree in Physician Studies
- 5 years’ experience as a Registered Nurse or EMT-P in a high touch clinical environment or home care; OR
- 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
The Community Advanced Practice Clinician ensures that a defined panel of dually eligible individuals receives the highest quality, primary care within the context of a member centric individualized plan of care.
As the Community APC you will have the opportunity to use evidence, clinical skills, education, and training to influence the clinical outcomes of CCA’s members by impacting acute care utilization, ensuring optimal treatment for chronic disease management, closing of quality gaps, participation in Annual/Geriatric Assessments, goals of care conversations, advance care planning, and delivering palliative and end of life care.As the Community APC you will maintain close contact and collaboration with the member’s network PCP, providers, and specialists in the development and implementation of clinical plans of care.
As an integral part of an Inter-professional Care Team and based on the fluctuating needs of the defined panel of members, you will engage in regular assessments, visits at regularly scheduled intervals, and conduct acute visits to ensure that members’ Plan of Care is comprehensive and addresses significant medical, behavioral, and social needs. Engagement by the APC can occur in two different ways.
Episodic care is triggered by an acute event or significant change in condition of a member which necessitates close, short term follow up by an Advanced Practice Clinician. Longitudinal enhanced primary care is delivered to members who are medically complex, with limitations that create a barrier for traditional in office visits.
This 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.
This position will cover territory North of Boston (Haverhill, Methuen, Lawrence, N. Andover)
- You will be able to performs both urgent and routine visits on members to evaluate condition and add to the plan of care
- You will order appropriate medical testing to aid in the diagnosis and medical management of acute and chronic diseases
- You will also leverage CCA clinical resources (InstED) to avoid emergency room visits and inpatient admissions.
- We will also want you to evaluate test results, appropriately treat member illness and communication/collaborate plan with PCP
- In addition, you will be facilitate and/or deliver preventative care to members according the guidelines deemed appropriate by CCA
- You will engage in appropriate clinical collaboration with clinical experts, including the member’s PCP, CCA Medical Directors, and other CCA Advanced Practice Clinicians. Clinical Leadership. Guidelines may vary based on the individual make-up of the member and is based on age, comorbidities, etc.
- You will provide care to those who need it most by...
- If appropriate, provide medical and psychiatric bridge prescribing abilities for members in transition between providers
- Evaluate member’s HEDIS measure needs, write orders as appropriate to manage these gaps and follow up with PCP on results
- Assist with Advanced Care Planning, including establishing goals of care with members and obtaining MOLST forms
- Provides limited 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.
- You will need a minimum of a Master’s Degree in Nursing or a Master's Degree in Physician Studies
- 5 years’ experience as a Registered Nurse or EMT-P in a high touch clinical environment or home care; OR
- 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
