Assessment & Care Planning Nurse Practitioner

at USA Medical Staff (view profile)
Location Boston, Massachusetts
Date Posted July 19, 2021
Category Nurse Practitioner (NP)
Job Type Full Time


Salary range $ 100,000 - $ 115,000 - experience dependent


Bachelor’s Degree in Nursing

NP with active NP license in Commonwealth of Massachusetts, in good standing

1+ years’ experience in home care and/or community settings

Board Certified Nurse Practitioner with licensure in good standing in the Commonwealth of Massachusetts

Must have strong primary care skills. Proficient in taking medical history, performing physical exam and assessment.


Master’s Degree in Nursing


Job Description

Commonwealth Care Alliance’s (CCA) Assessment and Care Planning unit is primarily responsible to ensure adherence to high quality community-based assessments and member-centric care plans for CCA members.

The Assessment and Care Planning Nurse Practitioner conducts timely, high quality, accurate in-person annual comprehensive assessments and MDS assessments and documents person-centered care plan using data collected during the assessment process. This individual works collaboratively with other members of the Assessment and Care Planning Unit and staff in other departments as needed to support timely intervention designed to improve outcomes of CCA members.

The Assessment and Care Planning Nurse Practitioners reports to the Regional NP Manager/Supervisor

·       Conduct in-person assessments on members who needs both the Annual Comprehensive Assessment and MDS Reassessments. That include taking a detailed history, performing a physical examination, and documenting appropriate diagnosis in order to ensure capture of high-risk codes under CMS guidelines and Rating Category under MassHealth guidelines.

·       Perform 6month/annual MDS reassessments and annual comprehensive assessment based on program (every 6 months for SCO, annually for One Care)

·       Risk adjustment- Performs and documents Annual Comprehensive Assessments ensuring that CCA is properly funded and quality, patient-centered care plan is provided. Performs ongoing history. Exam and medical decision-making including pharmacotherapy in collaboration with internal and external providers.

·       Manages assessment activities through calendar and tracks 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

·       Complies with organization’s policy and procedures.

·       Ensures immediate referral to any time-sensitive services such as Behavioral Health, Long Term services and Supports, or Rehab.

·       Communicate any time-sensitive concerns or clinical urgency to NP Manager/Supervisor during or immediately following visits.

·       Facilitate warm hand-off to the care partner if there is an immediate need that needs to be addressed.

·       Current Mass Controlled Substances License required

·       Current DEA Controlled Substances License required

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