Care Planner Registered Nurse

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


Salary range $ 80,000 - $ 85,000 - experience dependent


Associate Degree in Nursing

RN with active registered nursing license in Commonwealth of Massachusetts, in good standing

2+ years experience in home care and/or community settings

1+ years of clinical experience in acute/medical surgical settings

Must be willing and able to travel to member’s homes in addition to working in an office environment occasionally


Bilingual candidates preferred

Experience with electronic medical record strongly preferred (eCW a plus)

Care Management experience strongly preferred

Job Description

Commonwealth Care Alliance’s (CCA) Care Planning Unit (CPU) is primarily responsible for developing and

ensuring adherence to high quality, member-centric care plans through timely execution of community-based

assessments for CCA members and ongoing tracking and monitoring.

The Care Planner conducts timely, high quality, accurate in-person assessments. This individual leverages the

Minimum Data Set (MDS) assessment and develops and documents person-centered care plan using data

collected during the assessment process. This individual works collaboratively with other members of the Care

Planning Unit and staff in other departments as needed to support timely interventions designed to improve

outcomes for CCA members.

Conducts in-person assessment visits. Documents templated summary of visit highlights; documents MDS

and develops initial person-centered Care Plan including current Service Plan within 48 hours of visit.

Communicates any time-sensitive concerns to Regional RN Supervisor and/or NP during or immediately

following visit.

• Reviews members with NP and BH Specialist staff in weekly Stratification meetings to validate Care Model

assignment and facilitate warm hand off to Care Partner

• Ensures immediate referral to any time-sensitive services such as Behavioral Health, Long Term Services

and Supports or Physical Therapy.

• Manages assessment activities through calendar and tracks status of completion

• Participates in assessing and improving quality within the scope of responsibilities and throughout the


• 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

Demonstrate integrity by working with passion, commitment, and honesty, acting in the best interests of

colleagues and members. Approach work in a collaborating and caring manner interacting with insight,

sincerity, and compassion. Demonstrate accountability by delivering on commitments, owning mistakes as well

as successes, and contributing to an empowering environment where the focus is on solving problems and

learning from errors. Recognize and respect diversity in all forms. Strive for excellence in the fulfillment of

CCA’s mission through quality, innovation, and continuous learning. Demonstrate initiative, flexibility, and

openness to change. Represent CCA and its clinical affiliates with professionalism. Keep current and proficient

with necessary skills and knowledge. Self-identify training and development needs relevant to work area and

responsibilities. Adhere to all applicable compliance requirements including but not limited to:

  • Complete required compliance training in a timely manner
  • Review Code of Conduct at least annually and promote and enforce CCA’s Code of Conduct
  • Promote and enforce CCA’s compliance program
  • Adhere to CCA’s Policy & Procedures
  • Promptly, in good faith, report any instances of suspected fraud, waste and abuse; suspected privacy
  • and/or security incidents; or any compliance concerns identified
  • Ensure confidentiality of member and company proprietary information is maintained


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