Nurse Practitioner/Physician Assistant (Springfield Clinic and Virtual Visits from home)

Why This Role is Important to Us

Founded in 1977 the practice known today as CCA Primary Care is a Massachusetts based provider nationally recognized as a leader in the care of individuals facing complex challenges.

Today, CCA Primary Care’s impact is wider than it has ever been serving over a thousand of individuals across the state.

Join a team committed to serving complex individuals with the best possible care in a unique, comprehensive and quality focused model.

We are a specialized interdisciplinary team engaged in collaborative care with a wide range of resources at our fingertips.

Our goal is to improve the lives of the people we serve and help keep them at home, by providing best in class disability competent primary care.

The CCA Primary Care NP / PA provides comprehensive primary care to a panel of patients. Ideal candidates will have experience or interest in working with people who have complex physical, developmental, cognitive, and behavioral health conditions.

The Primary Care NP / PA works 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, urgent care, and includes acting as a liaison with other health professionals as needed.

Our care is delivered in the office, home, and virtually where appropriate.

Supervision Exercised :

No, this position does not have direct reports.

What You'll Be Doing

Essential Duties & Responsibilities :

• 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 patient and are based on age, comorbidities, etc.

• Identify and initiate a plan to meet quality, STAR, and HEDIS measures.
• Conduct Annual Visits with patients, taking a detailed history, performing a physical examination, and documenting appropriate diagnoses to develop a comprehensive medical care plan and ensure capture of high-risk diagnoses 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 prescribe medication assisted treatment (MAT) for some conditions when clinically appropriate.
• To achieve a key goal of decreasing admissions and re-admission, 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.
• Provide clinical coverage for colleagues in an equitable way.
• 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.

Working Conditions :

Standard office conditions and work locations include residential and community sites.