Palliative Care Nurse Practitioner or Physician Assistant
Commonwealth Care Alliance
Location: Charlestown , Massachusetts
Type: Full Time
Advanced Practice Registered Nurses / Physician Assistants
Internal Number: 22-884
The Palliative Care NP provides consultative specialty services related to serious illness impacts on members and caregivers and care coordination to a defined panel of CCA member's needs. The panel of members will be comprised of individuals with serious illness and may have significant behavioral, psychosocial and medical complexities that require intensive clinical support (in addition to that provided by the member's primary care provider) that help decrease barriers to fully and successfully accessing the health care system.
The Palliative Care NP is the part of a team responsible for the clinical, behavioral health, and care coordination related to serious illness for their panel of members. Responsibilities include: care coordination with internal and external providers, liaison with other relevant providers around medical, chronic disease, behavioral health and long-term service and support needs, and the provision (with support) of end of life/palliative care, as needed. Role also includes a compendium of care coordination functions encompassing the development and implementation of the member-centered individualized care plan inclusive of correct identification/ coding of diagnosis related to serious illness.
The Palliative Advanced Practice NP/PA provides clinical oversight of members referred to Palliative Care. The Palliative Advanced Practice Manager reports to the Palliative Program Manager, with clinical oversight by the Palliative Director (MD).
Conducts thorough assessments of members identified as having Palliative Care needs including but not limited to: accurate history and physical assessment, medication reconciliation, goals of care identification, psychosocial/spiritual needs assessment, symptom management identification and plan
Determines and documents appropriate follow-up plans in line with member goals and communicates these plans with member and caregivers
Completes ACP documents as appropriate
Reviews and includes the most appropriate diagnosis codes, in addition to correct billing and procedure codes.
Engages other team members to help address needs of members, through participation in family meetings or referrals as needed
Collaborates with and provides recommendations for outside Documents these suggestions and contacted providers
Provides oversight and coordinates prescriptions and delivery for members on service with Collaborative Care Partners and end of life panel
Completes documentation within 24 hours of visit
Engages with outside providers in a meaningful, partnership-driven Identifies and suggests opportunities for education that may help further understanding of Palliative Care tenants to continue engagement.
Participates in multidisciplinary team meetings and works towards Palliative Care strategic objectives
Mentor and coach new staff as requested
Problem-solves local issues and engages in professional conflict management
Identify and communicate opportunities for operational improvement under direction of Palliative Program Manger to improve the performance of CCA
Assesses appropriateness of incoming requests and team's processes over time to suggest opportunities for improvement
Participates in work groups as requested for process or service delivery improvement
Provides education to stakeholders as requested
Shows an ongoing commitment to learning about the tenants of Palliative Care through ongoing pursuit of education
Provide clinical care to members via telehealth technologies (video, chat, etc.) for a clinically appropriate clinical care and care management services.
Master's Degree in Nursing
Certified in Basic Life Support for Healthcare Providers
Hospice and Palliative Care certification
3+ years practicing in Hospice, Palliative care or end of life care setting
Experience caring for patients/members facing end of life with complex medical, behavioral health, and social needs strongly preferred.
Board Certified Nurse Practitioner or Physician Assistant with licensure in good standing
Demonstrate clinical competence in all aspects of primary care, care management, assessment, care planning, diagnosing and coding
Excellent interpersonal skills demonstrated by ability to interact professionally with culturally and educationally diverse staff and patients
Experience with electronic medical records preferred
Experience working with Medicare /Medicaid populations or populations with significant complexity of medical, behavioral and social
Ability to manage significant change
Excellent communication skills
Ability to teach, mentor, and coach
Ability to quickly shift gears and move in a new direction without clear guidance
Willing to learn and utilize telehealth technologies (video, chat, etc.), when appropriate, for a variety of clinical care and care management services.
Travel to the following towns:
Weston, Wellesley, Dover, Dedham, Newton, Newton Center, Newton Highlands, Newton Upper Falls, Newton Falls Lower, Chestnut Hill, Waban, Auburndale, Newtonville, Brighton, Watertown, Belmont, Cambridge, Allston, Somerville, Medford, and Charlestown
Based in Boston, Commonwealth Care Alliance® (CCA) is a not-for-profit, integrated care system influencing innovative models of complex care nationwide. Mission-based and person-centered, CCA is singularly focused on sustainable and evidence-based healthcare breakthroughs that fill important gaps in care and improve the health and well-being of people with significant needs. This includes advocating for affordable, high-quality, and cost-effective healthcare policies that lead to healthcare equity for individuals who need it most.CCA’s unique model of uncommon care® has achieved an unparalleled track record of improved health and quality outcomes and lower costs of care. In 2021, CCA began a multi-year, mission-aligned geographic diversification growth strategy to extend its proven care model throughout the United States. With its newly launched health plans in Massachusetts and Rhode Island and recent acquisitions in California and Michigan, CCA serves nearly 62,000 individuals across four states.