Job description

• Facilitates preventative and basic primary care to members, as needed, per CCA standard operating procedures, commonly accepted medical guidelines, and appropriate scope of
• Provides 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
• Performs annual comprehensive telephonic assessments and coordinates any needed follow up from results
• Coordinates a host of benefits such as transportation, LTSS, interpreter services, hospice services, and more.
• Adheres 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
• Performs 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
• Liaises with CCA interdisciplinary site team where applicable to ensure comprehensive member needs are consistently met
• Manages panel-wide and member-specific utilization trends
• Liaises with CCA and community-based PCPs/specialists
• Collaborates with the Transitions of Care Team on all medical and psychiatric admissions to assist in discharge planning
• Reviews approved authorizations to assess appropriate utilization, based on members' needs
• Actively participates in the evaluation of own performance and progress
• Participates in activities and education to maintain and advance competency
• Participates in CCA quality improvement efforts
• Provide clinical care to members via telehealth technologies (video, chat, etc.) for a clinically appropriate clinical care and care management services

• Associate degree or Diploma in Nursing; BSN or related healthcare Degree preferred
• Must have an active RN license in good standing in the state assigned, may require multiple state licenses based on product
• CCM preferred
• 2+ years meaningful clinical experience in primary care or care management including telephonic based setting, home health or acute care case management. Past experience caring for patients/members with complex medical, behavioral health, and social needs strongly preferred.
• Experience with a Medicare Advantage population preferred.
• Ability to use SBAR 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 of the benefits of CCA
• Ability to review welcome packets and obtain consent forms and attach them to EMR
• Ability to complete and update a Care Plan that meets CCA requirements
• Demonstrated understanding of LTSS
• 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, BH)
• Ability to conduct Crisis assessments over the phone and deploy assistance as needed
• Demonstrated ability of how to locate current guidelines for recommended screening tests and immunizations
• Demonstrated understanding of Referral to Specialists
• Demonstrates the 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 preferred

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