- Physician Assistant License
Why This Role is Important to Us:
The Clinical Liaison to the Health Homes (HHs) is responsible for providing clinical guidance and performance management support to the HHs located in Western and Central Massachusetts: Behavioral Health Network (BHN), Community Healthlink (CHL), and Advocates. The NP/PA will ensure successful execution of CCA's model of care by key community partners who are delegated for care management.
This position will provide clinical consultation for the HHs, and engage clinical and other CCA resources for optimal program oversight and support. The NP/PA will support the Clinical Manager and Program Director by contributing to strategic program development to ensure program success and growth.
What You'll Be Doing:
Clinical Performance: Responsible for supporting the Health Homes program to ensure harmonization with CCA’s model of care, clinical performance improvement, goal-setting, and monitoring and improvement plans, in close partnership with Program Director, Clinical Manager, and other teams. Proactively review data to identify trends and areas for focused care coordination and utilization management support; organize performance improvement initiatives.
Clinical Mentorship: Lead monthly clinical meetings with each HH to discuss complex cases and troubleshoot clinical operations processes; identify gaps and training needs; engage additional CCA clinical resources when needed. Collaborate with HH leadership to improve clinical documentation completeness, appropriateness, and to assess that Key Performance Indicators are being met via routine chart reviews and team audits.
Clinical Care: Conduct joint visits with Health Home staff for complex cases; refer / link with additional specialized CCA resources as needed. Complete a total of approximately 50 ACAs annually for BHN, CHL, and Advocates by taking a detailed history, performing a physical examination, and documenting appropriate diagnosis in order to ensure capture of high risk codes under CMS guidelines. Act a “bridge prescriber” (in conjunction with support from CCA medical and psychiatric medical directors) if member is transitioning between PCP and/or psychiatrist. Identify members for case consultation and/or transfer between Health Homes and CCA care teams and facilitate smooth transitions.
Quality Improvement: Support the HHs from a clinical perspective to improve performance on performance metrics. Proactively review performance data and propose actions to improve performance on timely submission of initial and re-assessment MDSs, 48 hour post discharge visits, and inpatient admissions.
Utilization: Identify high utilizers of services and use data to proactively target complex members for MER reduction, utilization management, and improved care management.
What We're Looking For:
Active NP or PA license in the state of Massachusetts.
At least a Masters’ Degree in Nursing or Master’s in Physician Assistant Studies.
Registered or eligible to be registered with the Massachusetts Department of Public Health and the Federal Drug Enforcement Agency.
Flexible, comfortable building / augmenting workflows without existing or with an ineffective structure.
At least five years of NP/PA clinical experience, including demonstrated interest in working with an underserved population with complex behavioral health diagnoses.
Knowledge of CCA’s model, culture, staff, and resources preferred.
Keywords: NP, nurse practitioner, PA, physician assistant, master’s, MSN, clinical, liaison, performance management, model of care, care management, community health, Health Homes, DPH, department of public health, DEA, complex care, behavioral health, utilization management, community health, Springfield, Worcester, Framingham, MA, Massachusetts