The Community Registered Nurse ensures that a defined panel of enrolled individuals receives the highest quality, primary and community based skilled care within the context of a member centric individualized plan of care. The Community Registered Nurse has the opportunity to use evidence, clinical skills, education, and training to influence the clinical outcomes of CCA’s members by impacting acute care utilization, ensuring optimal treatment for chronic disease management, closing of quality gaps, LTSS and home based community services utilization, , goals of care conversations, advance care planning, providing skilled nursing services that allow for optimal self-management, and supporting palliative and end of life care. The Community Primary Nurse will maintain close contact and collaboration with the member’s network PCP, providers, and specialists in the development and implementation of clinical plans of care.

As an integral part of an Interprofessional Care Team and based on the fluctuating needs of the defined panel of members, the Community Registered Nurse will engage in regular assessments, visits at regularly scheduled intervals, and conduct acute visits to ensure that members’ Plan of Care is comprehensive and addresses significant medical, behavioral, and social needs.

The Community Registered Nurse is supported by a fully staffed interprofessional care team that has, at its core, a Care Partner who is accountable for all aspects of care management and care coordination. The Community Registered Nurse collaborates with the entire care team, and keeps the Care Partner well informed on members’, providing critical clinical information that helps drive the overall ICP. The Community Registered Nurse will make adjustments to the ICP as indicated, identifying gaps and, in concert with the Care Partner, will leverage covered benefits to ensure that the right mix of services are in place to meet the member’s unique needs.

This position requires in person visits to members in their homes and will support members across various locations

The Community RN reports to the team Clinical Manager

• Associate's Degree or Diploma in nursing required,Bachelor's Degree in nursing preferred.
• Meaningful clinical experience in primary care or care management, including:
• 5+ years' experience as Registered Nurse in a high touch clinical environment or home care; OR2+ years caring for patients/members with complex medical, behavioral health, and social needs
• Registered Nurse with licensure in good standing in the state assigned to work
• Certified in Basic Life Support for Healthcare Providers.
• Current CPR or Basic Life Support (BLS)
• Demonstrate an understanding of the benefits of CCA's product lines
• Is able to conduct and document a Pain Assessment
• Is able to use SBAR Communication
• Is able to conduct and document Home Safety EvaluationIs able to provide Wound Care (simple & complex)
• Is able to utilize an Electronic Medical Record
• Is able to use on-line training platforms
• Demonstrates an understanding of the Model of Care
• Demonstrates an understanding of the benefits of each program
• Is able to review welcome packets and obtain consent forms and attach them to EMR
• Demonstrates an understanding of when an updated assessment is needed
• Is able to complete a comprehensive Assessment
• Is able to complete and update a Care Plan that meets CCA requirements
• Demonstrates an understanding of LTSS
• Demonstrates an understanding of how to use CDSTs when ordering services
• Is able to complete and lock all required notes and telephone encounters within 48 hours
• Participates in case discussions
• Ability to conduct Crisis assessments over the phone and deploy assistance as needed
• Able to lead a family/team meeting for the purposes of discharge planning
• Obtains/documents a comprehensive history
• Demonstrates knowledge and ability to use screening/ assessment tools to Fall risk assessment
• Assist with Advanced Care Planning, including establishing goals of care with members
• 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