Location: Springfield, MA
CCA Primary Care NP/PAs provide
s comprehensive interdisciplinary primary care to Commonwealth Care Alliance (CCA) members. Interested candidates should have experience or interest in working with people who have complex physical, developmental, intellectual, and behavioral health conditions. The Primary Care NP/PA work s closely with an interdisciplinary care team and must be comfortable guiding and coordinating care with those involved in the patient’s medical and behavioral care. This role will provide ongoing chronic disease consultation and management, promote preventative care through education and identification of age-appropriate preventative screens, and includes liaison with other health professionals as needed. Care is delivered in the office, home, and virtually where appropriate.
- Provide clinical care to your patients in clinic, through home visits, and utilizing telehealth technologies (video, chat, etc.).
- Facilitate, and deliver preventative care to patients according to guidelines deemed appropriate by CCA Clinical Leadership. Guidelines may vary based on the individual makeup of the patient and are based on age, comorbidities, etc.
- Identify and initiate a plan to meet all quality, STAR, and HEDIS measures.
- Conduct Annual Wellness Visits with patients, taking a detailed history, performing a physical examination, and documenting appropriate diagnoses in order to develop a comprehensive medical care plan and ensure capture of high-risk codes under CMS guidelines.
- Perform episodic urgent medical visits to ensure that patients are given timely and appropriate medical care in order to avoid emergency room visits or hospitalization. Such visits include a detailed history of present illness, review of systems, physical exam, ordering of appropriate studies and tests, identification of a differential diagnosis, development of a treatment plan, and evidence of follow up through timely documentation.
- Prescribe medically necessary and appropriate medications, in consultation with the physician where needed. Primary Care APCs are expected to e-prescribe through our electronic medical record and must have a DEA license and Massachusetts Controlled Substance Registration and be willing to obtain an X waiver when required.
- To decrease risk of readmissions, perform post discharge visits on patients within two weeks of discharge from either an acute care facility or a skilled nursing facility; perform detailed medication reconciliation and adjust medications as indicated. Visit will include history of causes for recent admission, review of systems, physical exam, ordering of appropriate diagnostic tests or studies, determination of diagnosis, and development of a treatment plan, including consideration of long-term services and supports or community resources that could help prevent another hospitalization.
- Independently make complex medical decisions, manage time, and prioritize tasks.
- Ensure appropriate and timely documentation of visits and activities within patient’s medical record.
- Liaison with internal care team as well as external medical and surgical specialists as necessary.
- Provide consultation and support to other members of the care team.
- Participate in team case review and practice meetings.
- Maintain appropriate written and oral communication on a timely basis.
- Actively participate in the evaluation of own performance and progress.
- Participate in activities and education to maintain and advance competency.
- Participate in CCA Primary Care’s quality improvement efforts and strategic initiatives. Opportunity to join and participate in Clinical Operations Committee and/or the Primary Care Clinical Advisory Council.
- Assist management and leadership with the development, refinement and enhancement of clinical programs, initiatives, processes, policies, workflows, and projects.
- Support new and existing staff through mentoring, teaching opportunities, and in‐services as able.
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
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
- 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