Job description

• Facilitate preventative and basic primary care to members, as needed, per CCA standard operating procedures, commonly accepted medical guidelines, and appropriate scope of practice.
• Provide regularly scheduled telephonic calls to support the management of chronic disease or end of life.
• Assist the member with understanding their CCA Health Benefit package.
• Perform annual comprehensive telephonic assessments and coordinate any needed follow up from results.
• Coordinate a host of benefits such as transportation, community resources, interpreter services, hospice services, and more.
• Adhere to appropriate and complete documentation practices, including history of present illness, adjustment, or maintenance of an established treatment plan, and consistent follow up of the plan as evidenced in the documentation.
• Perform episodic urgent medical/ behavioral health telephone calls and facilitates such visits are conducted in-person for applicable members on panel to ensure that timely and appropriate medical care in order to avoid emergency department visit or hospitalization.
• Liaise with CCA interdisciplinary site team where applicable and IPA clinical teams to ensure comprehensive member needs are consistently met
• Manage panel-wide and member-specific utilization trends.
• Liaise with CCA and community-based PCPs/specialists
• Collaborate with the Transitions of Care Team on all medical and psychiatric admissions to assist in discharge planning.
• MA / MI only: Reviews approved authorizations to assess appropriate utilization, based on members' needs
• Actively participate in the evaluation of own performance and progress.
• Participate in activities and education to maintain and advance competency.
• Participate in CCA quality improvement efforts.
• Provide services via telehealth technologies (video, chat, etc.) for clinically appropriate clinical care and care management services.

• Care Partners work remotely. Must have strong internet signal.
• Must be able to come to the local CCA office for various meetings as needed.
• May require participation in meetings across multiple states via Zoom or telephone.

• Associate degree or Diploma in Nursing; BSN or related healthcare Degree preferred.
• CCM preferred
• Must have an active RN license in good standing in the state assigned; may require multiple state licenses based on product
• 2+ years meaningful clinical experience in primary care or care management including telephonic based setting, home health or acute care case management.
• Experience with a Medicare Advantage population preferred.
• Past experience caring for patients/members with complex medical, behavioral health, and social needs strongly preferred.
• Experience with electronic medical records strongly preferred
• Ability to use SBAR (Situation, Background, Assessment, Recommendation) Communication
• Ability to utilize an Electronic Medical Record or other electronic platforms
• Ability to use on-line training platforms
• Demonstrated understanding of CCA's Model of Care
• Demonstrated understanding CCA member benefits
• Ability to review welcome packets, obtain consent forms and attach them to EMR (Electronic Medical Record)
• Ability to complete and update a Care Plan that meets CCA requirements
• Demonstrated understanding of how to use CDSTs when ordering services
• Ability to create referrals and authorize services within appropriate time frames
• Ability to complete and lock all required telephone encounters within 48 hours
• Ability to lead a family/team meeting for the purposes of discharge planning
• Demonstrated knowledge and ability to use screening/ assessment tools (e.g., Fall risk assessment, mini cog assessment, nutritional assessment, PHQ 2, PHQ 9,)
• Ability to conduct Crisis assessments over the phone and deploy assistance as needed
• Demonstrated ability to locate current guidelines for recommended screening tests and immunizations
• Demonstrated understanding of Referral to Specialists
• Demonstrated ability to utilize virtual care platforms
• 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 Spanish/Vietnamese preferred

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