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Full Job Description

Why This Role is Important to Us:

Commonwealth Community Care’s (CCC) Primary Care NP/PA provides comprehensive primary care consultation and management to adults of all ages, familiar with those who have complex physical, developmental, intellectual, and behavioral health conditions, requiring medical evaluation and care. Care is delivered in the office, home, and crisis stabilization unit setting. The Primary Care NP/PA works closely must be comfortable guiding the medical care in an interdisciplinary care team involved in the designated member’s behavioral care . This role will provide ongoing chronic disease consultation and management. and promote preventative care through education and identification of age appropriate preventative screens. The role also includes liaison with other health professionals as needed.

What You’ll Be Doing:

    • Within a defined time period of consultation request,, perform an exam and provide a verbal and documented set of recommendations;* On an annual basis, conduct an Annual Comprehensive Assessments on assigned members or designated members taking a detailed history, performing a physical examination, and documenting appropriate diagnosis in order to ensure capture of high risk codes under CMS guidelines;
    • Facilitate, and if appropriate deliver preventative care to members according the 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, co morbidities ,etc. Identify and initiate a plan to resolve areas of opportunity to meet quality
    • Provide follow up to the initial consultative visits for the management of chronic disease or acute medical illness during the episode of care at the crisis stabilization unit: Visits are inclusive of a review of consultation question, 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 during the episode of care at the crisis stabilization units;.
    • Perform episodic urgent medical visits to ensure that designated 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.
    • In order to decrease risk of readmissions for Behavioral Health Intensive members who have had medical admissions, perform post discharge visits on designated members within 48‐hours of discharge from either an acute care facility or a skilled nursing facility; perform detailed medication reconciliation and adjust medications as indicated with the guidance of the the primary care provider. Visit will include history of causes for recent admission, review of systems, physical exam, ordering of appropriate diagnostic tests or studies, determination of a diagnosis, development of a treatment
    • Ensure appropriate documentation of visits and activities within CCA’s central enrollee record and within the record of partners as indicated;

    Liaison with internal and external primary care provider and medical/surgical specialists as necessary;

    • Act as a mentor to other team members to help promote/foster accountability, reliability, and independence among the other team members
    Provide consultation and support to other members of CCA Care Team
    • Participate in Team Case Review
    • Maintains appropriate written and oral communication on a timely basis, completing documentation within 24 hours of activity, and returning non‐urgent calls within 48 hours
    • Actively participate in the evaluation of own performance and progress
    • Participate in activities and education to maintain and advance competency
    • Participates in CCA Quality Improvement efforts
    • Assists CCA management and leadership with the development, refinement and enhancement of clinical programs, initiatives, processes, policies, workflows, and projects
    • Participate in committees and workgroups that promote clinical excellence and help to advance CCAs mission and business objectives
    • Supports Clinical Education Team by mentoring new and existing staff and offering teaching opportunities and in‐services as able
    • Requires ability for independent complex medical decision making as well as independent time management and prioritization of work tasks.
    • Advanced level of job complexity, makes independent clinical decisions daily that affects clinical and financial outcomes. Serves as a lead and a consultant to the interdisciplinary care team on complex care planning.

    Provide clinical care to members via telehealth technologies (video, chat, etc.) for a clinically appropriate clinical care and care management services.

What We’re Looking For:

Required:

Master’s Degree in Nursing, Doctor of Nursing Practice or a degree in Physician Assistant Studies (ADD)

  • Board Certified Nurse Practitioner or Physician Assistant with licensure in good standing in the Commonwealth of
  • Will be required to pass CCA’s credentialing
  • Current Mass Controlled Substances License required
  • Current DEA Controlled Substances License required/ Suboxone Certification desired
  • Current CPR or Basic Life Support (BLS) Certification
Required:

2‐3 years of hands on clinical experience, defined as:

  • Substantial nursing experience prior to NP (2 or more years as an RN) in a high‐touch clinical environment or home care
  • 1‐2 years of NP experience (preferably in primary care)
  • Or 2+ years of PA experience
Required:
  • Proven skills, knowledge base, and judgment necessary for independent clinical decision making. Excellent organizational, time management and problem solving skills. Ability to function effectively as part of a multi‐disciplinary team. Effective oral and written skills. Strong interpersonal and customer relations skills. Effective teaching skills.
  • Willing to learn and utilize telehealth technologies (video, chat, etc.), when appropriate, for a variety of clinical care and care management services.
English required,
Bilingual preferred

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