The primary functions of the C-APC role are delivering care to medically complex CCA members, providing care management, and collaborating with external providers with the goal of delivering comprehensive care.
Essential Duties include: Best in class member care; Clear, concise, and effective communication and documentation; and Interdisciplinary collaboration with a variety of stakeholders internally and externally.
Perform longitudinal routine, and urgent care for an attributed member panel including:
Medical and Psychiatric post hospital discharge visits within 48 hours with focus on hospitalization and utilization reduction
Longitudinal chronic disease management within Complex Care Self-Management (CCSM) program
Annual Wellness Visits
Goals of Care conversations, including completion of HCP and MOLST forms
Minimum Data Set (MDS) assessments
Long Term Services and Supports (LTSS) assessments and referrals to LTSS providers
Proactive and routine well-visits and preventative care
Urgent, episodic, or un-well visits
Point of care testing and venipuncture
Routine medical follow ups and monitoring
Conduct multiple member visits within each business day balancing routine, scheduled encounters with episodic or urgent visits.
Prescribe or bridge prescribe medications based on medical evaluation for acute and chronic conditions independently and in collaboration with PCP and/or external providers.
Evaluate for and prescribe necessary Durable Medical Equipment (DME).
Monitor response to action or treatment plan with appropriate evaluation and adjustments.
Initiate necessary action or treatment changes adhering to CCA Policies and Procedures and within scope of licensure.
Evaluate HEDIS Measure Gaps and work towards closure of gaps in clinical practice and in collaboration with member's external providers.
Evaluate Hierarchical Condition Categories (HCC) and work to recapture.
Leverage emergency medical or psychiatric services as indicated to mitigate Emergency Services and inpatient admissions (instED, Crisis Response Unit, Medical Director, Behavioral Health Clinicians, etc.)
Document all visits with focus on clear, comprehensive, and concise charting.
Must be able to document in English.
Identify, document, and execute a member-centric plan of care.
Ability to communicate and delegate care plan as appropriate utilizing multiple modalities of communication.
Completion of all tasks within appropriate timelines as outlined in Scopes of Practice and CCA Guidelines.
Comply with organizational policies and procedures.
Maintain member and employee confidentiality.
Interdisciplinary Team Collaboration:
Serve as a clinical mentor and leader on the IDT
Proactively and collaboratively work with members Primary Care Provider (PCP) and other external providers to ensure a cohesive medical treatment plan is delivered.
Conduct on-going and effective collaboration and communication with external providers, including but not limited to Primary Care staff, specialty services, LTSS coordinators, Aging Service Access Points (ASAPs), visiting nurse services, care attendants, member designated contacts, and next of kin.
Conduct on-going and effective collaboration and communication with interdisciplinary team including but not limited to, Clinical Group Care Partners, Community Registered Nurses, Community Health Workers, Behavioral Health Clinicians, Medical Directors, Palliative Care Team, Psychiatric services team, Rehab Team, Crisis Response workers, Member Services representatives, administrative staff, and CCA Leaders.
Identify and lead ad hoc case reviews with internal/external care team as needed.
Participate in IDT Meetings by:
(a) presenting member cases for IDT Review; and
(b) serving as clinical leader on IDT, offering insights and teaching to IDT Members.
The Regular Part-Time C-APC performs the above duties in the following manner:
Work two , eight  hour shifts and one , four  hour shift per week
Attend Team Meeting every other week (Twice monthly participation and at least monthly case presentation).
Scheduling is dependent on when team meeting occurs.
Attend all mandatory education and training sessions, including onboarding, compliance, regulatory, and skills-based trainings to maintain skills competency.
Mandatory education and training sessions may occur on a day you are not normally scheduled to work.
Master's Degree in Nursing, Doctor of Nursing Practice or a degree in Physician Assistant Studies
Required Licensure: Board Certified Nurse Practitioner or Physician Assistant with licensure in good standing in the Commonwealth of Massachusetts
Must meet one of the following requirements:
2+ years' experience as NP or PA caring for patients/members with complex medical, behavioral health, and social needs; preferred experience in primary care or care management setting; OR
1-year experience as NP or PA in primary care or care management AND 3+ years' experience as Registered Nurse or EMT-P in a high touch clinical environment or home care; OR
If new NP or PA graduate, must have 5+ years' experience as Registered Nurse or EMT-P in a high touch clinical environment or home care.
Experience with electronic medical record strongly preferred (eCW and Guiding Care a plus)
Experience working with managed care population
Experience with MassHealth or Medicare programming and insurance products (i.e. ACO, MCO, PACE, or SCO)
Candidate will be required to pass CCA's credentialing process.
This includes, but is not limited to:
Current Mass Controlled Substances License required
Current DEA Controlled Substances License required
Current CPR or Basic Life Support (BLS) Certification Required
Proven skills, knowledge base, and judgement necessary for independent clinical decision making in alignment with clinical licensure, ability to problem solve.
Sufficient visual/hearing ability, with or without reasonable accommodation, to comprehend written/verbal communication and perform physical exams and assessments of patients
Strong and effective communication skills, written, verbal, and via electronic modalities
Effective teaching skills
Mediation and conflict resolution skills
Effective organizational and time management skills
Ability to advocate for a complex patient population in a culturally competent manner
Willing to learn and utilize telehealth technologies (video, chat, etc.), when appropriate, for a variety of clinical care and care management services.
Demonstrated ability to utilize and toggle through multiple EHR platforms
Equal Opportunity Employer Minorities/Women/Protected Veterans/Disabled
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