Commonwealth Care Alliance’s (CCA) Weekend Advanced Practice Clinician (APC) is an NP or PA primarily responsible for providing short-term in-person episodic care and care management to a flexible panel of dually-eligible CCA members, a group of individuals with significant medical, behavioral, and social complexities that require intensive clinical support.The APC provides short term, episodic enhanced primary care to a flexible panel of dually-eligible members from both the SCO and One Care population.
The need for the weekend APC 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.The weekend APC will complete at least one ACA per week and focus on post discharge visits to decrease the readmission rate.The role also includes performing a discrete set of care management/care coordination functions, including the adjustment of tthe member centric care plan and authorization of appropriate durable medical equipment and services.
Key Responsibilities: 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 the guidelines deemed appropriate by CCA Clinical Leadership. Guidelines may vary based on the individual make-up of the member and is based on age,
comorbidities, etc. - Identifies and initiates a plan to resolve areas of opportunity to meet quality metrics.
- Provides limited regularly scheduled follow up visits for the management of chronic disease or end of life/palliative care. 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. - In order to decrease 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.
- Liaises with CCA Care Partner and community based PCPs/ Specialists, as needed
- 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 CCA 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 CCA internal resources, ensures that the plan of care is implemented in a timely manner. - Performs defined functions of the authorization process as indicated by CCA policies and procedures.
- Palliative care consultations and skilled interventions
- Meaningful clinical experience in primary care or care management, includiing
- 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
- 1+ years as CCA Care Partner (or prior similar role) strongly preferred
- Board Certified NP or Physician Assistant with licensure in good standing in the Commonwealth of Massachusetts.
- Will be required to pass CCA’s credentialing process.
- Current Mass Controlled Substances License required
- Current DEA Controlled Substances License required
- Current CPR or Basic Life Support (BLS) Certification
Working Hours: Exempt employee, FTE (40 hours)
Friday: 8:30 – 5:00
Saturday: 8:30 am – 9:00 pm
Sunday: 8:30 am – 9:00 pm
