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SCO Complex Care Nurse Practitioner - Boston North

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POST DATE 9/8/2016
END DATE 11/5/2016

Tufts Health Plan Watertown, MA

Watertown, MA
AJE Ref #
Job Classification
Full Time
Job Type
Company Ref #
Entry Level (0 - 2 years)


Under the administrative direction of the Clinical Manager, the Complex Care Clinician (CCC) for Senior Care Options (SCO), who is required to be a licensed Nurse Practitioner, is responsible to coordinate all aspects of member care for a panel of medically complex, frail older adults with advanced illness. Members may live in a community based setting or a nursing home for long term care.

The CCC directly interfaces with physicians, other members of the primary care team, members, and their caregivers in identifying risk factors, conducting physical exams and state required assessments, diagnosing and prescribing, and developing and implementing care plans to comprehensively manage these high risk members.


The Complex Care Clinician will have a clear understanding of the role and will demonstrate a commitment to executing on the following responsibilities:
* Conducting initial and follow-up clinical cassessments
* Performing physical examinations that may include:
o Past medical history
o Review of systems
o Physical examination
o Medication review
o Depression screening
o Pain assessment
o Responsible for checking vitals, conducting monofilament test, and foot exam (as appropriate)
o Identify diagnoses to be used in care management and active medical management in the furtherance of treatment
o Formulate a list of current and past medical conditions using clinical knowledge and judgment and the findings based on the assessment process
o Review of quality measures
* Communicate findings in the assessment that will be used to inform the PCP and PCT of potential gaps in care.
* Facilitating clarification of patient and family goals of care and advanced directives.
* Ensuring plan of care is in place, including anticipatory guidance and planning.
* Facilitating access to appropriate support models of care i.e. hospice, rehabilitation and on-going aggressive treatment
* Informing primary care physician of recommended services and collaborating with other physicians as needed.
* Facilitating Primary Care Team meetings.
* Consulting with the primary care physician, care managers, specialists, and other involved providers to contribute to the patient's plan of care.
* Collaborating with the care manager to ensure facilitation of member and caregiver access to community resources relevant to the member's needs, including referrals to Adult Day Health, Adult Foster Care and the Personal Care Attendant Program.

* Managing and coordinating all transitions of care, including:
o Communicating care plan to providers in all settings of care (ED, hospital, rehabilitation facility, nursing home, home care) and ensuring providers receive timely clinical data that may impact healthcare treatment decisions

* Providing education and coaching to the member, family, and/or caregiver about health status, treatment options, goals of care, and health insurance benefits to assist members in making the most informed decisions and help promote self management.

Required Qualifications:
* Advanced Practice Nurse with current, unrestricted Massachusetts license required
* Valid prescriptive authority from both the MA DPH-DCP and Federal DEA required
* Bilingual (Spanish or Portuguese) preferred

* Experience in a hospice or palliative care setting required
* Experience in case management managing geriatric/chronic illness populations required
* Experience within a SCO program highly preferred
* Experience in Medicare and/or Medicaid managed care preferred
* Proficient in computer use, the Internet, and health information technology required
* Experience in Behavioral Health preferred

Skill Requirements:
* Work cooperatively as a team member across multiple levels within the organization
* Demonstrate initiative in achieving individual, team, and organizational goals and objectives
* Must be able to prioritize work and develop strategies for adapting to constantly changing priorities and urgencies.
* Regard for confidential data and adherence to corporate compliance policy
* Demonstrate cultural competency and sensitivity
* Demonstrate the ability to work autonomously

Other Requirements:
* Ability to travel frequently to member's homes, hospitals, skilled nursing facilities, PCP office practices and other sites where patients receive care.

Equal Opportunity Employer Minorities/Women/Protected Veterans/Disabled


Founded in 1979 as a non-profit health maintenance organization (HMO), Tufts Health Plan is one the country's largest HMO offering a full array of healthcare coverage options to individual consumers and employer groups. Tufts Health Plan has received high marks for its quality from a variety of third parties including U.S News & World Report and Newsweek.