Assessment RN Worcester North

023430 Clin Alli-Clin Assessment & CP Position Summary Commonwealth Care Alliance’s (CCA) Assessment unit conducts initial and ongoing face-to-face assessments for CCA enrollees. The Unit is also responsible for evaluating the accuracy and quality of all assessments and ensuring timely submission to MassHealth. The department includes registered nurse assessors and reviewers. The assessors are organized into teams and geographically dispersed across the commonwealth The Assessment nurse conducts timely, high-quality, accurate in-person assessments. These individuals leverage the Minimum Data Set (MDS), Comprehensive, and Functional Assessment using data collected during the assessment process to identify the member's concerns and unmet needs. This individual works collaboratively with other members of the care team and staff in other departments as needed to support timely interventions designed to improve outcomes for CCA members. The Assessment nurse reports to the Regional RN Supervisor. Supervision Exercised No, this position does not have direct reports. Essential Duties & Responsibilities Conducts in-person assessment visits and clinical exams, if appropriate, and relevant screenings within assigned territory as scheduled to capture members’ clinical needs and meet regulatory requirements. Medication reconciliation, adherence concerns, vital signs, and acute and chronic disease education. Complete additional tools or screeners as needed, including relevant behavioral health screeners (PHQ-9, EASI, Audit, DAST). Uses clinical judgment to escalate members with urgent needs to the Regional RN Supervisor and / or manager during or immediately following the visit. Utilize our electronic health record, scheduling platforms, and claims platforms to collect data, document member interactions, organize information, and communicate with your team, members, and care team. Understanding of how to use electronic health record systems and / or care management platforms to ensure accurate documentation. Willing and able to pivot to various tasks as needed to support the needs of the department best. Adaptable to change and prepared for frequent, fast-paced changes and shifting priorities. Ensures immediate referral to time-sensitive services such as behavioral health, long-term services, and support. Manages assessment activities through the calendar and tracks the status of completion. Participates in assessing and improving quality within the scope of responsibilities and throughout the organization. Participates in activities and education to maintain and advance clinical competencies Seeks to maintain a constructive work environment and maintains effective communication with other employees and managers. Maintains confidentiality of patient and employee information. Compliance with the organization’s policies and procedures. Provide clinical assessments to members via telehealth technologies (video, chat, etc.) when clinically appropriate. Use the data collected during the assessment to identify member concerns and unmet needs so that the care team can develop and formalize an individualized care plan. Collaborate with care team members to determine whether members need to be placed in a different program (for example, lower or high-intensity programs). Working Conditions Work locations include residential and community sites. Must be willing and able to travel to member’s homes and work remotely occasionally. Valid driver’s license with no restrictions. Ability to be active and mobile across Massachusetts Member Facing ☒ YES : The job has in-person contact (not telephonic / virtual) with CCA members or patients as part of the job duties. Required Education (must Have) Associate degree in Nursing RN with an active registered nursing license in the Commonwealth of Massachusetts, in good standing. Desired Education (nice To Have) Bachelor's Degree in Nursing Required Licensing (must Have) RN with an active registered nursing license in the Commonwealth of Massachusetts, in good standing. MA Health Enrollment (required If Licensed In Massachusetts) No, this is not required for the job. Required Experience (must Have) 1 years of clinical experience including clinical rotation Desired Experience (nice To Have) Experience with electronic medical records strongly preferred Care Management experience Required Knowledge, Skills & Abilities (must Have) Proven skills and knowledge base necessary for conducting clinical assessments, clinical decision-making and care delivery. Ability to function independently. Excellent organizational skills. Ability to function effectively as part of a team. Effective oral and written skills Strong Interpersonal and customer relation skills. Effective teaching skills. Intermediate to Advanced understanding of Microsoft Office Suite. Willing to learn and utilize telehealth technologies (video, chat, etc.), when appropriate, for a variety of clinical care and care management services. Required Language (must Have) English Required Desired Knowledge, Skills, Abilities & Language (nice To Have) Bilingual in English and second language