Why This Role is Important to Us:

　　CCA's Complex Care II, Registered Nurse (RN), will focus on CCA members presenting to the Emergency Department (ED), partnering with the emergency room providers to create pathways to manage these members at home, avoiding unnecessary admissions. The Complex Care II RN extends the CCA outpatient model of patient-centered complex care management to the inpatient hospital setting, providing consultation for inpatient care teams to assure high-quality, effective, and efficient patient-centered acute care for hospitalized members. The Complex Care II RN will work with a specialized team of Complex Care Hospitalists, Community Health Workers, Behavioral Health Specialists, and Community Paramedics to be able to address acute medical needs as well as psycho-social elements that often drive hospitalizations. This team will be able to authorize and execute rapid home interventions, such as same/ next day visits by advanced practice clinicians, IV meds and labs, and in-home PT/OT and other skilled nursing services.

　　This position will report to the Acute Care Medical Director.

　　What You'll Be Doing:

　　The RN will provide consultation on CCA patients who present to the ED to help with acute care evaluation and medical management, work together to formulate appropriate disposition and consider the possibility of ED diversion using CCA's innovative models: Mobile integrated health via community paramedicine for next day IV meds and labs as well as community advanced practice clinicians for next day home visits and clinical management.

　　The RN will round on select CCA patients within 24 hours of admission and work with the inpatient team to formulate the plan of care.

　　Collaborate with the inpatient hospital team, CCA Transitions of Care team, the outpatient care team and the community primary care physician to provide updates on patient's progress while in the hospital.

　　Coordinate with palliative care and other CCA subspecialty services.

　　Interact regularly with patient and families to ensure that they are informed and feel that CCA partners with them in their care.

　　Actively participates in the planning, implementation and coordination of health education and counseling of the patient and family.

　　Teaches families and caretakers how to provide safe, effective care and promote optimum function for patients at home.

　　Documents the level of understanding and response to teaching.

　　Documents all activities and results using an Electronic Medical Record, in an effective manner while strictly adhering to CCA policies and procedures.

　　Collaborates with CCA Care Partner and community-based PCPs/ Specialists, as needed.

　　Collaborates with CCA interdisciplinary site team to ensure comprehensive member needs are consistently met

　　Attends weekly Interprofessional Team Meetings

　　Ensures that the plan of care is implemented in a timely manner.

　　Identifies members who require escalation to the APC or MD for further evaluation

　　Working Conditions:

　　COVID-19 vaccination is requiredWhat We're Looking For:

　　Qualifications:

　　Diploma or Associates degree in nursing from an accredited institution,Bachelor's Degree in Nursing Preferred

　　A minimum of 5+ years of experience as a board-certified Registered Nurse in Massachusetts with significant experience working in the Emergency Department.

　　Proven ability to collaborate effectively as a part of an interdisciplinary team

　　Be a creative problem solver capable of rapidly implementing unique care plans.

　　Have an interest and experience in serving complex, vulnerable and disabled populations is essential

　　Strong bedside manner

　　Have experience with quality improvement, monitoring and evaluation, health systems strengthening, innovation and training is desired, although not essential

　　Proven skills, knowledge base and judgment necessary for independent clinical decision-making

　　Excellent organizational, time management, and problem-solving skills.

　　Strong and effective communication skills, both written and verbal

　　Strong interpersonal and customer relations skills

　　Effective teaching skills

　　Mediation, facilitation, and conflict resolution skills

　　Demonstrates analytical skills necessary to review data

　　Experience with electronic medical records

　　Experience with Microsoft applications

　　Experience with virtual care platforms

　　English required, bi-lingual preferred

　　EEO is The Law

　　Equal Opportunity Employer Minorities/Women/Protected Veterans/Disabled

　　Please note employment with CCA is contingent upon acceptable professional references, a background check (including Mass CORI, employment, education, criminal check, and driving record, (if applicable)), an OIG Report and verification of a valid MA/RN license (if applicable). Commonwealth Care Alliance is an equal opportunity employer. Applicants are considered for positions without regard to veteran status, uniformed service member status, race, color, religion, sex, national origin, age, physical or mental disability, genetic information or any other category protected by applicable federal, state or local laws.