Care Delivery RN Admissions Coordinator

Position Summary:
Commonwealth Care Alliance's (CCA) Care Delivery service lines are responsible for providing care delivery and care management to a specific panel of high risk and complex people. This panel of CCA's patients incorporates the care of individuals with significant medical, behavioral, and social complexities that require intensive care management and care delivery.

The Care Delivery Admissions Coordinator reports to the Patient Access Manager and will help maintain Care Delivery programming at levels that the department is staffed for, provide initial outreach to patients to explain services and schedule initial visits for the assigned clinician. The RN in this role will also be reviewing Algorithm Identified Patient Referrals, Health Plan Referrals and Palliative Smart List to review CCA Health Plan members identified with Care Delivery needs in the CCA electronic health records to clinically validate finding and assure that the member is an appropriate referral, is in the home or SNF setting where Care Delivery team members can visit in-person to perform assessments and coordinate the referral to the appropriate Care Delivery team.

This role will complement the data-driven outcomes Care Delivery achieves by tracking outcomes, opportunities and developing KPIs to achieve best results through feedback to the vendor and utilizing and developing unique reports for tracking outcomes and progress towards them.

Supervision Exercised:
* No, this position does not have direct reports.

Essential Duties & Responsibilities:
* Patient Care Support:
* This role requires superb communication skills, the ability to speak with members and their caregivers in a health-literate way as well as with internal and external providers.
* Review members identified for Care Delivery in the electronic health records to independently clinically validate findings for program admission.
* Communicate to PCP and Health Plan team in a succinct way and tracking for approval needed to proceed with the admission.
* Assure that the referred member is in the home or SNF setting where team members can visit in-person to perform assessments. Tracks outcomes and opportunities within different facilities to promote more effective member care.
* Perform initial outreach to member or healthcare surrogate to explain program in Care Delivery, obtain verbal consent for initial visit, schedule the same with the member or healthcare surrogate and assign clinician in coordination with clinician's supervisor.
* Participate with program leadership to independently track and assimilate conclusions around gaps in population health needs for the members served. Identifies process improvement opportunities and implements solutions
* Will also develop method for tracking data on admissions; outreach attempts and findings related to demographics and report them to leadership.
* Will assimilate trends on the populations in areas served, both members who successfully enroll as well as those who don't.
* Will identify quality improvement projects specific to population health for admissions and initiate KPIs to improve performance.
* Provide clinical care to members via telehealth technologies (video, chat, etc.) for clinically appropriate clinical care and care management services.
* Documentation of all interactions and interventions must be completed within established timelines while maintaining productivity standards
* Communication and Collaboration:
* Conduct on-going and effective collaboration and communication with interdisciplinary team including but not limited to, Health Plan Care Team, Community Advanced Practice Clinicians, Community Licensed Practical Nurses, Community Health Workers, Community Behavioral Health Clinicians, Medical Directors, Palliative Care Team, Psychiatric services team, Rehab Team, Crisis Response workers, Patient Services representatives, administrative staff, and CCA Leaders.
* Provides consultation and support to other members of Care Team
* Participates in on-going education and training to improve skills
* Assists management with the development, refinement and enhancement of clinical programs, initiatives, processes, policies, workflows, and projects.
* Participates in committees and workgroups that promote clinical excellence.
* Palliative Care:
* Requires extensive knowledge about Palliative vs Hospice care criteria, the ability to educate and support partnerships with external and internal customers.
* Review Smart List members identified with Palliative need in the CCA electronic health records to independently clinically validate findings for Serious Illness presence and Palliative care needs. This assimilation will need to be communicated to PCP and CP in a succinct way and tracking for approval needed to proceed with the admission.
* Will identify any opportunities within the Smart List for improvement to identify members with Palliative need more accurately and work with the vendor to implement changes.
* Other projects and requests as made by the Palliative Director
* Other duties as assigned

Working Conditions:
Standard office conditions.

* This position may require in-person visits to patients in their homes and will support patients across various locations.
* This position requires travel to CCA sites and offices per required need for various team meetings.
* Valid driver's license with no restrictions. Ability to be active and mobile across assigned catchment area.
* COVID-19 vaccination is required
* Compliance with all Community Clinician Occupational Health Requirements.

Other:

Equipment Utilized
* Standard office equipment
* Experience with electronic medical record strongly preferred eCW a plus)

Physical Requirements
* The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job.
* Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
* While performing the duties of this job, the employee is regularly required to stand; use hands to finger, handle, or feel; reach with hands and arms; and talk or hear.
* The employee is occasionally required to walk; sit; and stoop, kneel, crouch, or crawl
* The employee must frequently lift and/or move up to 10 pounds and occasionally lift and/or move more than 100 pounds.
* Specific vision abilities required by this job include close vision, distance vision, and ability to adjust focus.
* Must be able to come to the local CCA office
* May require meetings across the state